| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
583 |
577 |
$33K |
| D1110 |
Prophylaxis - adult |
355 |
354 |
$28K |
| D1120 |
Prophylaxis - child |
734 |
726 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
422 |
418 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
287 |
287 |
$13K |
| D1206 |
Topical application of fluoride varnish |
468 |
468 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,517 |
839 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
644 |
635 |
$6K |
| D0274 |
Bitewings - four radiographic images |
142 |
142 |
$3K |
| D0272 |
Bitewings - two radiographic images |
30 |
29 |
$277.50 |