| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
192 |
192 |
$13K |
| D1110 |
Prophylaxis - adult |
143 |
142 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
172 |
172 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
83 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
133 |
132 |
$2K |
| D2161 |
|
27 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
125 |
124 |
$2K |
| D0274 |
Bitewings - four radiographic images |
58 |
58 |
$1K |
| D1120 |
Prophylaxis - child |
53 |
53 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
107 |
106 |
$530.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
73 |
52 |
$356.00 |