| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
378 |
373 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
799 |
797 |
$16K |
| D1206 |
Topical application of fluoride varnish |
718 |
717 |
$15K |
| D1120 |
Prophylaxis - child |
147 |
147 |
$5K |
| D0274 |
Bitewings - four radiographic images |
161 |
161 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
146 |
145 |
$2K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
45 |
$550.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$540.54 |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
13 |
$515.70 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$438.34 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$372.45 |