| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
629 |
628 |
$13K |
| D1110 |
Prophylaxis - adult |
503 |
502 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
716 |
706 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
785 |
765 |
$3K |
| D0274 |
Bitewings - four radiographic images |
252 |
251 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
53 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
79 |
79 |
$863.50 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$240.00 |