| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
252 |
250 |
$18K |
| D1120 |
Prophylaxis - child |
244 |
243 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
98 |
98 |
$7K |
| D0274 |
Bitewings - four radiographic images |
243 |
241 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
587 |
566 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
371 |
369 |
$4K |
| D1110 |
Prophylaxis - adult |
42 |
42 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
70 |
70 |
$3K |
| D1206 |
Topical application of fluoride varnish |
51 |
51 |
$861.40 |