| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
573 |
573 |
$39K |
| D1110 |
Prophylaxis - adult |
286 |
285 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,726 |
1,035 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,095 |
1,092 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
125 |
123 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
124 |
124 |
$5K |
| D4910 |
|
67 |
67 |
$5K |
| D1120 |
Prophylaxis - child |
120 |
120 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
272 |
266 |
$3K |
| D0274 |
Bitewings - four radiographic images |
123 |
123 |
$3K |