| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
166 |
152 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
200 |
188 |
$3K |
| D1120 |
Prophylaxis - child |
73 |
73 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
97 |
97 |
$1K |
| D0274 |
Bitewings - four radiographic images |
43 |
42 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
46 |
$943.63 |
| D1206 |
Topical application of fluoride varnish |
77 |
67 |
$877.70 |
| D0272 |
Bitewings - two radiographic images |
41 |
40 |
$657.74 |
| D0220 |
Intraoral - periapical first radiographic image |
64 |
50 |
$460.35 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
17 |
$409.44 |