| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
186 |
161 |
$329.00 |
| D0210 |
Intraoral - complete series of radiographic images |
78 |
59 |
$174.00 |
| D1206 |
Topical application of fluoride varnish |
244 |
204 |
$171.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
110 |
86 |
$114.00 |
| D0140 |
Limited oral evaluation - problem focused |
34 |
27 |
$70.00 |
| D0120 |
Periodic oral evaluation - established patient |
92 |
80 |
$56.00 |
| D0220 |
Intraoral - periapical first radiographic image |
150 |
123 |
$39.00 |
| D0603 |
|
179 |
150 |
$22.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
123 |
84 |
$18.00 |
| D1120 |
Prophylaxis - child |
62 |
49 |
$0.00 |
| D4921 |
|
40 |
15 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
68 |
52 |
$0.00 |
| D1330 |
|
575 |
472 |
$0.00 |
| D1310 |
|
555 |
455 |
$0.00 |