| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
132 |
132 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
200 |
200 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
239 |
239 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
230 |
225 |
$3K |
| D0274 |
Bitewings - four radiographic images |
106 |
106 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
48 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
220 |
169 |
$2K |
| D4910 |
|
16 |
16 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$923.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$520.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$420.00 |