| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
118 |
117 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
74 |
74 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
248 |
207 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
47 |
47 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$630.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$350.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
60 |
58 |
$201.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$144.00 |