| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,003 |
1,002 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
728 |
728 |
$48K |
| D1110 |
Prophylaxis - adult |
382 |
382 |
$34K |
| D1120 |
Prophylaxis - child |
683 |
683 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
507 |
507 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,003 |
1,218 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
868 |
868 |
$11K |
| D0272 |
Bitewings - two radiographic images |
763 |
763 |
$9K |
| D4910 |
|
25 |
25 |
$2K |
| D9430 |
|
53 |
51 |
$2K |
| D1206 |
Topical application of fluoride varnish |
101 |
101 |
$1K |
| D0274 |
Bitewings - four radiographic images |
60 |
60 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
69 |
$840.00 |