| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
319 |
314 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
468 |
462 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
118 |
118 |
$2K |
| D1110 |
Prophylaxis - adult |
50 |
50 |
$768.00 |
| D1120 |
Prophylaxis - child |
25 |
25 |
$325.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$286.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
19 |
19 |
$234.00 |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$187.50 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$108.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$33.00 |