| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
149 |
146 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
174 |
171 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
133 |
132 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$938.88 |
| D0220 |
Intraoral - periapical first radiographic image |
157 |
151 |
$925.40 |
| D0274 |
Bitewings - four radiographic images |
44 |
44 |
$837.48 |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$774.08 |
| D0140 |
Limited oral evaluation - problem focused |
37 |
36 |
$707.44 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$461.76 |
| D0230 |
Intraoral - periapical each additional radiographic image |
106 |
101 |
$439.04 |