| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
676 |
643 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
719 |
648 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
174 |
148 |
$7K |
| D0274 |
Bitewings - four radiographic images |
229 |
204 |
$6K |
| D0330 |
Panoramic radiographic image |
120 |
107 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
239 |
202 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
171 |
152 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
80 |
75 |
$935.50 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$459.59 |
| D1120 |
Prophylaxis - child |
16 |
13 |
$369.98 |