| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
267 |
267 |
$14K |
| D1110 |
Prophylaxis - adult |
313 |
313 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
320 |
320 |
$7K |
| D4341 |
|
67 |
27 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
380 |
379 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
254 |
254 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
109 |
108 |
$1K |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$722.85 |
| D0230 |
Intraoral - periapical each additional radiographic image |
62 |
59 |
$489.90 |