| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
287 |
282 |
$340.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
692 |
675 |
$275.01 |
| D1120 |
Prophylaxis - child |
141 |
140 |
$214.63 |
| D0120 |
Periodic oral evaluation - established patient |
395 |
390 |
$211.94 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
92 |
88 |
$187.12 |
| D0220 |
Intraoral - periapical first radiographic image |
91 |
85 |
$120.00 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$100.00 |
| D0274 |
Bitewings - four radiographic images |
124 |
124 |
$92.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
13 |
$0.00 |