| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,489 |
1,475 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
827 |
815 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
605 |
600 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
683 |
670 |
$1K |
| D0272 |
Bitewings - two radiographic images |
341 |
334 |
$945.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
417 |
403 |
$621.50 |
| D1120 |
Prophylaxis - child |
29 |
29 |
$252.00 |
| D0210 |
Intraoral - complete series of radiographic images |
52 |
52 |
$208.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$180.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$160.00 |
| D1999 |
|
12 |
12 |
$0.00 |