| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
111 |
110 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
97 |
96 |
$2K |
| D1206 |
Topical application of fluoride varnish |
57 |
53 |
$937.50 |
| D0274 |
Bitewings - four radiographic images |
76 |
75 |
$828.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$580.00 |
| D0220 |
Intraoral - periapical first radiographic image |
125 |
120 |
$560.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$495.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
71 |
70 |
$393.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$300.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$300.00 |