| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,753 |
1,676 |
$85K |
| D4341 |
|
711 |
298 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
1,859 |
1,801 |
$38K |
| D6010 |
|
27 |
12 |
$28K |
| D4381 |
|
250 |
79 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
817 |
720 |
$11K |
| D1330 |
|
730 |
721 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
285 |
276 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
226 |
164 |
$3K |
| D4342 |
|
31 |
17 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
55 |
$2K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$861.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$682.00 |
| D4910 |
|
17 |
12 |
$525.00 |