| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
207 |
206 |
$7K |
| D1110 |
Prophylaxis - adult |
107 |
107 |
$5K |
| D0274 |
Bitewings - four radiographic images |
150 |
150 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
195 |
194 |
$4K |
| D1120 |
Prophylaxis - child |
93 |
93 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
239 |
238 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
181 |
181 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$769.42 |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$328.10 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$287.87 |