| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
471 |
469 |
$27K |
| D1110 |
Prophylaxis - adult |
175 |
172 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
324 |
321 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
219 |
219 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
698 |
695 |
$7K |
| D1120 |
Prophylaxis - child |
208 |
207 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
905 |
429 |
$5K |
| D0274 |
Bitewings - four radiographic images |
191 |
191 |
$4K |
| D1206 |
Topical application of fluoride varnish |
162 |
159 |
$3K |
| D0350 |
|
34 |
33 |
$633.60 |