| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
261 |
261 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
599 |
594 |
$6K |
| D0274 |
Bitewings - four radiographic images |
169 |
169 |
$4K |
| D1120 |
Prophylaxis - child |
130 |
130 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
384 |
384 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
293 |
290 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
55 |
$2K |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$757.12 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$698.88 |