| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
447 |
447 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
170 |
170 |
$13K |
| D1120 |
Prophylaxis - child |
276 |
276 |
$12K |
| D0274 |
Bitewings - four radiographic images |
490 |
490 |
$11K |
| D1110 |
Prophylaxis - adult |
110 |
110 |
$10K |
| D4910 |
|
111 |
111 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
693 |
266 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
79 |
79 |
$901.00 |
| D1206 |
Topical application of fluoride varnish |
45 |
45 |
$725.50 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
29 |
$348.00 |