| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,406 |
1,398 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,487 |
1,478 |
$38K |
| D0274 |
Bitewings - four radiographic images |
456 |
456 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,084 |
1,069 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
130 |
130 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
133 |
132 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
619 |
614 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
41 |
$2K |
| D1206 |
Topical application of fluoride varnish |
39 |
39 |
$1K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$897.50 |