| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
615 |
614 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
415 |
413 |
$9K |
| D0274 |
Bitewings - four radiographic images |
444 |
441 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
145 |
144 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
695 |
681 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
512 |
503 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$511.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$357.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$186.00 |