| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
166 |
134 |
$4K |
| D1206 |
Topical application of fluoride varnish |
54 |
54 |
$1K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$938.40 |
| D1110 |
Prophylaxis - adult |
14 |
13 |
$471.90 |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
15 |
$412.75 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$402.24 |
| D0220 |
Intraoral - periapical first radiographic image |
49 |
41 |
$391.30 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
14 |
$357.76 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$332.64 |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$282.10 |