| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,480 |
1,480 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,308 |
1,307 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
1,273 |
1,272 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
459 |
459 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
351 |
351 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
1,252 |
1,249 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
350 |
342 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
346 |
346 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
90 |
90 |
$365.50 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$175.00 |