| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
720 |
583 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
322 |
317 |
$16K |
| D1110 |
Prophylaxis - adult |
136 |
136 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
148 |
148 |
$7K |
| D9910 |
|
119 |
116 |
$5K |
| D0330 |
Panoramic radiographic image |
175 |
170 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$585.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$551.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
12 |
$216.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$199.00 |