| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
352 |
352 |
$15K |
| D1110 |
Prophylaxis - adult |
178 |
178 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
220 |
220 |
$9K |
| D1120 |
Prophylaxis - child |
284 |
284 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
129 |
129 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,277 |
228 |
$5K |
| D4910 |
|
67 |
67 |
$5K |
| D1206 |
Topical application of fluoride varnish |
247 |
247 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
380 |
379 |
$3K |
| D4341 |
|
44 |
12 |
$3K |
| D9430 |
|
73 |
68 |
$2K |
| D0350 |
|
66 |
26 |
$652.80 |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$648.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$156.00 |