| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
810 |
801 |
$43K |
| D1120 |
Prophylaxis - child |
363 |
362 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,290 |
875 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
143 |
140 |
$8K |
| D0274 |
Bitewings - four radiographic images |
366 |
361 |
$8K |
| D1206 |
Topical application of fluoride varnish |
281 |
273 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
432 |
430 |
$4K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
122 |
116 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
24 |
$1K |
| D9430 |
|
24 |
24 |
$768.00 |
| D0350 |
|
44 |
26 |
$422.40 |