| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
324 |
323 |
$4K |
| D1110 |
Prophylaxis - adult |
250 |
247 |
$3K |
| D1206 |
Topical application of fluoride varnish |
347 |
346 |
$2K |
| D1120 |
Prophylaxis - child |
147 |
147 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
435 |
432 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
120 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
94 |
94 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
65 |
65 |
$1K |
| D0274 |
Bitewings - four radiographic images |
34 |
34 |
$261.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
62 |
62 |
$154.00 |