| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
277 |
274 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
721 |
690 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
276 |
259 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
512 |
494 |
$7K |
| D0274 |
Bitewings - four radiographic images |
173 |
170 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
163 |
160 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
32 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$372.00 |