| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
504 |
503 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
94 |
94 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
118 |
118 |
$4K |
| D1110 |
Prophylaxis - adult |
56 |
56 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
466 |
453 |
$3K |
| D9999 |
Unspecified adjunctive procedure, by report |
16 |
16 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
488 |
482 |
$2K |
| D0274 |
Bitewings - four radiographic images |
140 |
140 |
$871.20 |
| D1120 |
Prophylaxis - child |
43 |
43 |
$810.00 |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$250.00 |
| D0350 |
|
17 |
13 |
$190.80 |