| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
139 |
139 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
172 |
172 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
516 |
515 |
$3K |
| D0274 |
Bitewings - four radiographic images |
154 |
154 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
127 |
127 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
290 |
289 |
$1K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$325.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$260.00 |
| D0270 |
|
50 |
50 |
$250.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$225.00 |