| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
812 |
811 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,120 |
1,120 |
$29K |
| D1120 |
Prophylaxis - child |
373 |
373 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
397 |
397 |
$9K |
| D0274 |
Bitewings - four radiographic images |
227 |
227 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
406 |
402 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
86 |
85 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
59 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
249 |
214 |
$2K |