| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
529 |
527 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
400 |
400 |
$26K |
| D0350 |
|
2,145 |
541 |
$20K |
| D1110 |
Prophylaxis - adult |
224 |
224 |
$20K |
| D1120 |
Prophylaxis - child |
366 |
363 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
316 |
316 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,108 |
580 |
$12K |
| D1206 |
Topical application of fluoride varnish |
756 |
752 |
$12K |
| D0274 |
Bitewings - four radiographic images |
406 |
405 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
199 |
199 |
$2K |
| D9430 |
|
46 |
44 |
$1K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$750.00 |