| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
69 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
116 |
108 |
$3K |
| D1120 |
Prophylaxis - child |
89 |
80 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
397 |
156 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
188 |
179 |
$1K |
| D2140 |
|
23 |
12 |
$1K |
| D1351 |
Sealant - per tooth |
66 |
14 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
42 |
42 |
$907.20 |
| D1206 |
Topical application of fluoride varnish |
27 |
26 |
$258.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
12 |
$120.00 |