| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
674 |
674 |
$38K |
| D1110 |
Prophylaxis - adult |
275 |
275 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
250 |
250 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
316 |
316 |
$15K |
| D1120 |
Prophylaxis - child |
291 |
291 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
695 |
695 |
$8K |
| D0350 |
|
832 |
188 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
583 |
497 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,202 |
617 |
$5K |
| D0274 |
Bitewings - four radiographic images |
224 |
224 |
$5K |
| D1206 |
Topical application of fluoride varnish |
151 |
151 |
$2K |
| D9430 |
|
13 |
13 |
$416.00 |