| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
548 |
530 |
$17K |
| D0274 |
Bitewings - four radiographic images |
570 |
548 |
$12K |
| D0330 |
Panoramic radiographic image |
300 |
294 |
$11K |
| D1206 |
Topical application of fluoride varnish |
796 |
767 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
685 |
663 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
333 |
319 |
$8K |
| D1120 |
Prophylaxis - child |
301 |
293 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
281 |
272 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
602 |
568 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
33 |
33 |
$444.23 |
| D0230 |
Intraoral - periapical each additional radiographic image |
41 |
24 |
$278.12 |