| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
229 |
229 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
319 |
318 |
$4K |
| D1110 |
Prophylaxis - adult |
204 |
204 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
151 |
150 |
$2K |
| D1120 |
Prophylaxis - child |
131 |
131 |
$2K |
| D1206 |
Topical application of fluoride varnish |
202 |
202 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
71 |
70 |
$858.00 |
| D0220 |
Intraoral - periapical first radiographic image |
155 |
149 |
$356.25 |
| D0230 |
Intraoral - periapical each additional radiographic image |
52 |
51 |
$121.00 |
| D0601 |
|
12 |
12 |
$120.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$0.00 |