| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
703 |
702 |
$42K |
| D4910 |
|
356 |
356 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,772 |
778 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,078 |
1,075 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
835 |
755 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
149 |
149 |
$10K |
| D1120 |
Prophylaxis - child |
272 |
270 |
$9K |
| D1110 |
Prophylaxis - adult |
98 |
98 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
121 |
121 |
$6K |
| D0272 |
Bitewings - two radiographic images |
393 |
391 |
$5K |
| D4341 |
|
44 |
12 |
$3K |
| D9110 |
|
49 |
45 |
$3K |
| D0350 |
|
36 |
18 |
$345.60 |