| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
999 |
998 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
872 |
872 |
$23K |
| D0274 |
Bitewings - four radiographic images |
172 |
171 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
38 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
357 |
351 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
50 |
50 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
249 |
211 |
$788.25 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$752.50 |
| D1120 |
Prophylaxis - child |
15 |
15 |
$706.50 |