| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
743 |
716 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
785 |
767 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
670 |
621 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
186 |
171 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
113 |
105 |
$5K |
| D0274 |
Bitewings - four radiographic images |
156 |
153 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
372 |
323 |
$4K |
| D1206 |
Topical application of fluoride varnish |
61 |
58 |
$956.46 |
| D0330 |
Panoramic radiographic image |
25 |
24 |
$926.25 |
| D1120 |
Prophylaxis - child |
16 |
15 |
$424.86 |