| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,159 |
1,159 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
1,695 |
1,695 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,151 |
1,151 |
$19K |
| D1120 |
Prophylaxis - child |
490 |
490 |
$17K |
| D0274 |
Bitewings - four radiographic images |
592 |
592 |
$16K |
| D0272 |
Bitewings - two radiographic images |
780 |
780 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
171 |
171 |
$7K |
| D1206 |
Topical application of fluoride varnish |
282 |
282 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
84 |
84 |
$3K |
| D2160 |
|
31 |
12 |
$3K |
| D0330 |
Panoramic radiographic image |
63 |
63 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
124 |
123 |
$2K |