| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
696 |
695 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
502 |
501 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
198 |
198 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
772 |
722 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
110 |
110 |
$3K |
| D1206 |
Topical application of fluoride varnish |
54 |
54 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
58 |
56 |
$1K |
| D0274 |
Bitewings - four radiographic images |
64 |
64 |
$792.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
179 |
179 |
$648.00 |