| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
73 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
105 |
90 |
$2K |
| D1110 |
Prophylaxis - adult |
75 |
68 |
$2K |
| D1120 |
Prophylaxis - child |
57 |
51 |
$1K |
| D1206 |
Topical application of fluoride varnish |
83 |
75 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
72 |
68 |
$930.92 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$744.75 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$484.59 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$268.40 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
13 |
$207.48 |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
14 |
$171.60 |