| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
54 |
52 |
$3K |
| D0240 |
|
273 |
110 |
$3K |
| D1110 |
Prophylaxis - adult |
83 |
78 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
83 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
69 |
67 |
$1K |
| D0274 |
Bitewings - four radiographic images |
60 |
56 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
40 |
38 |
$558.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
53 |
40 |
$256.50 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$226.00 |
| D0220 |
Intraoral - periapical first radiographic image |
49 |
43 |
$221.50 |