| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
44 |
42 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
64 |
60 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
78 |
76 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
98 |
95 |
$1K |
| D1120 |
Prophylaxis - child |
18 |
18 |
$773.25 |
| D1206 |
Topical application of fluoride varnish |
20 |
20 |
$767.52 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$365.64 |
| D0230 |
Intraoral - periapical each additional radiographic image |
86 |
39 |
$341.62 |
| D0274 |
Bitewings - four radiographic images |
21 |
21 |
$306.41 |