| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
226 |
226 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
290 |
290 |
$8K |
| D1206 |
Topical application of fluoride varnish |
438 |
438 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
168 |
167 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
80 |
80 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
291 |
288 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
172 |
139 |
$1K |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$1K |
| D4910 |
|
14 |
14 |
$980.00 |
| D0602 |
|
63 |
63 |
$627.00 |
| D0603 |
|
28 |
28 |
$308.00 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
15 |
$70.00 |