| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
401 |
392 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
590 |
579 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
691 |
683 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
196 |
196 |
$5K |
| D0274 |
Bitewings - four radiographic images |
184 |
184 |
$3K |
| D1120 |
Prophylaxis - child |
152 |
145 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
149 |
143 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
64 |
38 |
$481.79 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
26 |
$387.36 |