| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
481 |
480 |
$12K |
| D1110 |
Prophylaxis - adult |
222 |
221 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
147 |
138 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
172 |
172 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
304 |
297 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$1K |
| D0274 |
Bitewings - four radiographic images |
111 |
111 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
153 |
151 |
$831.00 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$675.00 |