| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
414 |
412 |
$2K |
| D1206 |
Topical application of fluoride varnish |
426 |
425 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
102 |
102 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
392 |
383 |
$1K |
| D1110 |
Prophylaxis - adult |
182 |
181 |
$987.00 |
| D0274 |
Bitewings - four radiographic images |
188 |
188 |
$928.00 |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
40 |
$928.00 |
| D1120 |
Prophylaxis - child |
113 |
113 |
$840.00 |
| D0140 |
Limited oral evaluation - problem focused |
131 |
130 |
$735.00 |
| D4910 |
|
78 |
77 |
$700.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
314 |
275 |
$396.00 |
| D0602 |
|
76 |
74 |
$263.00 |
| D1999 |
|
45 |
38 |
$0.00 |
| D4921 |
|
33 |
14 |
$0.00 |
| D0601 |
|
18 |
16 |
$0.00 |