| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
255 |
249 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
264 |
264 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
43 |
40 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
57 |
$2K |
| D0274 |
Bitewings - four radiographic images |
47 |
47 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
45 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$520.26 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
24 |
$295.50 |