| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
136 |
131 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
119 |
119 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,335 |
391 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
84 |
82 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
293 |
293 |
$3K |
| D0274 |
Bitewings - four radiographic images |
76 |
76 |
$2K |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |