| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
56 |
50 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
94 |
86 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
27 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
30 |
$740.00 |
| D0220 |
Intraoral - periapical first radiographic image |
119 |
101 |
$500.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$300.00 |
| D0274 |
Bitewings - four radiographic images |
25 |
24 |
$192.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$45.00 |