| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
824 |
779 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
669 |
654 |
$15K |
| D0272 |
Bitewings - two radiographic images |
140 |
139 |
$3K |
| D1206 |
Topical application of fluoride varnish |
81 |
78 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
23 |
23 |
$977.00 |
| D0140 |
Limited oral evaluation - problem focused |
21 |
20 |
$644.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
42 |
$493.00 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
24 |
$414.00 |