| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
240 |
225 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
217 |
194 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
405 |
350 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
56 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
98 |
89 |
$965.56 |
| D1320 |
|
105 |
93 |
$795.00 |
| D0210 |
Intraoral - complete series of radiographic images |
21 |
19 |
$660.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
157 |
117 |
$425.00 |
| D0274 |
Bitewings - four radiographic images |
52 |
43 |
$384.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$240.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$180.00 |