| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,434 |
1,432 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
2,123 |
2,120 |
$45K |
| D4910 |
|
655 |
653 |
$44K |
| D1206 |
Topical application of fluoride varnish |
2,369 |
2,364 |
$44K |
| D0274 |
Bitewings - four radiographic images |
845 |
845 |
$20K |
| D0603 |
|
952 |
952 |
$10K |
| D1120 |
Prophylaxis - child |
190 |
190 |
$7K |
| D1330 |
|
627 |
627 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
129 |
129 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
49 |
49 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
81 |
78 |
$3K |
| D0330 |
Panoramic radiographic image |
78 |
78 |
$988.00 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
28 |
$351.00 |