| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
476 |
476 |
$11K |
| D1110 |
Prophylaxis - adult |
180 |
180 |
$8K |
| D1120 |
Prophylaxis - child |
226 |
226 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
417 |
415 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
215 |
215 |
$3K |
| D0274 |
Bitewings - four radiographic images |
86 |
86 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
74 |
74 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
122 |
122 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$802.20 |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$443.00 |
| D0270 |
|
12 |
12 |
$148.85 |