| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
44 |
42 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
74 |
70 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
91 |
85 |
$1K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$603.68 |
| D0230 |
Intraoral - periapical each additional radiographic image |
63 |
28 |
$529.46 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$441.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$346.10 |
| D0220 |
Intraoral - periapical first radiographic image |
32 |
32 |
$314.00 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$288.50 |
| D0603 |
|
127 |
121 |
$0.02 |