| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
126 |
126 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
182 |
182 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
65 |
65 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
147 |
139 |
$3K |
| D1206 |
Topical application of fluoride varnish |
78 |
78 |
$2K |
| D0274 |
Bitewings - four radiographic images |
58 |
58 |
$2K |
| D1120 |
Prophylaxis - child |
44 |
44 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
19 |
17 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
117 |
85 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$1K |