| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0191 |
|
143 |
128 |
$3K |
| D1110 |
Prophylaxis - adult |
138 |
137 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
135 |
135 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
66 |
$2K |
| D1120 |
Prophylaxis - child |
45 |
44 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
233 |
225 |
$990.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
172 |
170 |
$811.59 |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$525.00 |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$424.85 |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$289.50 |