| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
328 |
328 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
317 |
317 |
$7K |
| D0274 |
Bitewings - four radiographic images |
188 |
188 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
317 |
317 |
$1K |
| D1120 |
Prophylaxis - child |
41 |
41 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
42 |
$945.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
260 |
260 |
$801.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
41 |
41 |
$635.50 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$455.00 |