| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
624 |
624 |
$21K |
| D0274 |
Bitewings - four radiographic images |
795 |
795 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
696 |
696 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
996 |
994 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
645 |
644 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
144 |
144 |
$3K |
| D1120 |
Prophylaxis - child |
49 |
49 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
49 |
49 |
$332.45 |
| D0140 |
Limited oral evaluation - problem focused |
29 |
28 |
$275.73 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$7.59 |