| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
171 |
171 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
194 |
194 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
70 |
68 |
$3K |
| D0274 |
Bitewings - four radiographic images |
78 |
78 |
$2K |
| D1120 |
Prophylaxis - child |
57 |
57 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
92 |
92 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$653.68 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$281.60 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
13 |
$188.30 |