| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
128 |
127 |
$4K |
| D0274 |
Bitewings - four radiographic images |
117 |
116 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
152 |
149 |
$3K |
| D1120 |
Prophylaxis - child |
99 |
98 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
95 |
95 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
108 |
106 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
148 |
124 |
$970.76 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$637.95 |
| D0230 |
Intraoral - periapical each additional radiographic image |
35 |
35 |
$312.08 |
| D0140 |
Limited oral evaluation - problem focused |
18 |
17 |
$269.90 |