| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
372 |
304 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
466 |
391 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
661 |
552 |
$2K |
| D1206 |
Topical application of fluoride varnish |
359 |
341 |
$2K |
| D1120 |
Prophylaxis - child |
132 |
129 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
89 |
83 |
$619.56 |
| D0230 |
Intraoral - periapical each additional radiographic image |
237 |
206 |
$612.06 |
| D0274 |
Bitewings - four radiographic images |
69 |
61 |
$468.07 |
| D1208 |
Topical application of fluoride, excluding varnish |
90 |
67 |
$256.05 |