| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
151 |
151 |
$10K |
| D1110 |
Prophylaxis - adult |
58 |
58 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
79 |
79 |
$4K |
| D1206 |
Topical application of fluoride varnish |
225 |
219 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
25 |
25 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
45 |
$639.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
120 |
80 |
$615.60 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$496.80 |