| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
237 |
237 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
304 |
303 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
278 |
274 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
613 |
577 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
115 |
113 |
$3K |
| D1120 |
Prophylaxis - child |
114 |
113 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
414 |
384 |
$2K |
| D0274 |
Bitewings - four radiographic images |
87 |
87 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
37 |
$858.04 |
| D0272 |
Bitewings - two radiographic images |
42 |
41 |
$390.00 |