| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
219 |
218 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
189 |
189 |
$9K |
| D1110 |
Prophylaxis - adult |
57 |
57 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
399 |
397 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
97 |
97 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
549 |
250 |
$2K |
| D1120 |
Prophylaxis - child |
63 |
63 |
$2K |
| D0274 |
Bitewings - four radiographic images |
86 |
85 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
98 |
87 |
$1K |