| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
196 |
193 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
153 |
145 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
91 |
91 |
$2K |
| D1120 |
Prophylaxis - child |
50 |
50 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
59 |
58 |
$2K |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$1K |
| D1206 |
Topical application of fluoride varnish |
29 |
29 |
$780.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$380.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
68 |
42 |
$303.75 |