| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
147 |
146 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
115 |
115 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
53 |
53 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
149 |
148 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
813 |
140 |
$765.45 |
| D0274 |
Bitewings - four radiographic images |
85 |
84 |
$600.60 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
28 |
$588.00 |
| D9920 |
|
42 |
12 |
$468.00 |
| D0220 |
Intraoral - periapical first radiographic image |
162 |
157 |
$420.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$252.00 |