| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
110 |
102 |
$3K |
| D1120 |
Prophylaxis - child |
69 |
69 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
91 |
$2K |
| D0274 |
Bitewings - four radiographic images |
134 |
123 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
59 |
59 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
161 |
151 |
$750.40 |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
31 |
$572.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
151 |
138 |
$532.00 |
| D1110 |
Prophylaxis - adult |
18 |
18 |
$431.80 |