| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
449 |
446 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
593 |
589 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
158 |
158 |
$5K |
| D0274 |
Bitewings - four radiographic images |
200 |
197 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
281 |
277 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
140 |
129 |
$4K |
| D1120 |
Prophylaxis - child |
147 |
146 |
$3K |
| D1206 |
Topical application of fluoride varnish |
56 |
56 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
205 |
195 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
131 |
56 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
13 |
$555.84 |