| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
783 |
783 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,128 |
1,123 |
$33K |
| D1206 |
Topical application of fluoride varnish |
447 |
445 |
$14K |
| D1120 |
Prophylaxis - child |
193 |
192 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
393 |
388 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
78 |
77 |
$3K |
| D0274 |
Bitewings - four radiographic images |
278 |
277 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
57 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
362 |
353 |
$2K |
| D0272 |
Bitewings - two radiographic images |
43 |
43 |
$430.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
86 |
86 |
$360.00 |