| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
299 |
259 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
154 |
116 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
208 |
173 |
$3K |
| D0274 |
Bitewings - four radiographic images |
124 |
109 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
71 |
$2K |
| D1120 |
Prophylaxis - child |
29 |
25 |
$1K |
| D1206 |
Topical application of fluoride varnish |
54 |
46 |
$689.25 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
12 |
$172.50 |
| D0220 |
Intraoral - periapical first radiographic image |
20 |
13 |
$94.52 |