| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
328 |
311 |
$4K |
| D1110 |
Prophylaxis - adult |
96 |
93 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
164 |
155 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
191 |
186 |
$3K |
| D0274 |
Bitewings - four radiographic images |
84 |
84 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
40 |
40 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$961.19 |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$942.21 |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$262.40 |