| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
277 |
277 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
103 |
103 |
$6K |
| D1206 |
Topical application of fluoride varnish |
281 |
277 |
$4K |
| D0350 |
|
356 |
147 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
724 |
433 |
$3K |
| D0274 |
Bitewings - four radiographic images |
99 |
99 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
37 |
$2K |
| D1120 |
Prophylaxis - child |
30 |
30 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$420.00 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$312.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$174.00 |