| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
71 |
54 |
$3K |
| D1110 |
Prophylaxis - adult |
57 |
52 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
53 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
89 |
83 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
62 |
56 |
$875.04 |
| D0274 |
Bitewings - four radiographic images |
33 |
33 |
$833.52 |
| D0220 |
Intraoral - periapical first radiographic image |
78 |
73 |
$639.21 |
| D0230 |
Intraoral - periapical each additional radiographic image |
90 |
41 |
$617.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
21 |
21 |
$311.64 |
| D1999 |
|
175 |
131 |
$30.24 |