| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
220 |
220 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
54 |
54 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
259 |
257 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
827 |
374 |
$3K |
| D4910 |
|
31 |
31 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
49 |
49 |
$2K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
122 |
107 |
$1K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$1K |
| D0350 |
|
103 |
27 |
$960.00 |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$799.20 |
| D1320 |
|
37 |
37 |
$647.50 |
| D9430 |
|
12 |
12 |
$384.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$176.00 |