| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
133 |
130 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
87 |
$6K |
| D1110 |
Prophylaxis - adult |
38 |
38 |
$3K |
| D4910 |
|
29 |
26 |
$2K |
| D1206 |
Topical application of fluoride varnish |
84 |
83 |
$1K |
| D0274 |
Bitewings - four radiographic images |
54 |
54 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
213 |
106 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$624.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$322.00 |