| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
136 |
132 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
265 |
242 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
96 |
95 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
210 |
186 |
$2K |
| D1110 |
Prophylaxis - adult |
43 |
43 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$905.55 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$529.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$273.80 |