| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
250 |
250 |
$16K |
| D1110 |
Prophylaxis - adult |
755 |
755 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
838 |
838 |
$15K |
| D0274 |
Bitewings - four radiographic images |
297 |
297 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
694 |
688 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
71 |
71 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
443 |
443 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
143 |
143 |
$2K |
| D1120 |
Prophylaxis - child |
71 |
71 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
80 |
80 |
$580.80 |