| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
89 |
84 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
231 |
206 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
190 |
170 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
63 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
89 |
75 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
105 |
90 |
$1K |
| D0272 |
Bitewings - two radiographic images |
14 |
12 |
$385.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$140.00 |