| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
600 |
566 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
833 |
779 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
553 |
501 |
$6K |
| D0272 |
Bitewings - two radiographic images |
200 |
193 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
499 |
288 |
$5K |
| D0274 |
Bitewings - four radiographic images |
50 |
38 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
41 |
40 |
$828.43 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$546.96 |