| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,330 |
2,324 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
2,699 |
2,686 |
$945.00 |
| D0274 |
Bitewings - four radiographic images |
2,022 |
2,012 |
$772.00 |
| D0220 |
Intraoral - periapical first radiographic image |
2,819 |
2,765 |
$436.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,884 |
1,877 |
$143.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
119 |
$70.00 |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$42.25 |
| D1120 |
Prophylaxis - child |
41 |
41 |
$31.25 |
| D1208 |
Topical application of fluoride, excluding varnish |
19 |
19 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$0.00 |