| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,140 |
1,118 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
548 |
539 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
190 |
189 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
1,268 |
1,208 |
$688.00 |
| D0120 |
Periodic oral evaluation - established patient |
632 |
624 |
$435.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
952 |
934 |
$381.75 |
| D1120 |
Prophylaxis - child |
89 |
89 |
$240.00 |
| D0274 |
Bitewings - four radiographic images |
65 |
65 |
$12.00 |
| D1206 |
Topical application of fluoride varnish |
26 |
26 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$0.00 |