| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
525 |
525 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,570 |
1,556 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
758 |
758 |
$16K |
| D0272 |
Bitewings - two radiographic images |
783 |
783 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
305 |
305 |
$9K |
| D0330 |
Panoramic radiographic image |
182 |
182 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,092 |
965 |
$8K |
| D1206 |
Topical application of fluoride varnish |
200 |
200 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
166 |
166 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$2K |
| D3120 |
|
52 |
37 |
$2K |
| D1120 |
Prophylaxis - child |
52 |
52 |
$2K |