| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
234 |
234 |
$6K |
| D1110 |
Prophylaxis - adult |
126 |
125 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
182 |
181 |
$4K |
| D1120 |
Prophylaxis - child |
73 |
72 |
$3K |
| D9110 |
|
39 |
38 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
313 |
305 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
86 |
75 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
240 |
232 |
$1K |
| D0274 |
Bitewings - four radiographic images |
59 |
59 |
$1K |
| D1206 |
Topical application of fluoride varnish |
28 |
28 |
$738.40 |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
30 |
$690.09 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
13 |
$364.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$96.43 |