| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
903 |
901 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
945 |
945 |
$21K |
| D0274 |
Bitewings - four radiographic images |
344 |
344 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
118 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
66 |
65 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
153 |
153 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
179 |
178 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
33 |
33 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
55 |
40 |
$682.00 |