| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
129 |
128 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
67 |
$3K |
| D0274 |
Bitewings - four radiographic images |
87 |
85 |
$2K |
| D1110 |
Prophylaxis - adult |
29 |
29 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
33 |
30 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
66 |
62 |
$788.28 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$132.60 |