| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
378 |
378 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
373 |
373 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,298 |
699 |
$14K |
| D4341 |
|
86 |
26 |
$6K |
| D4910 |
|
75 |
74 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
379 |
378 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
190 |
180 |
$2K |
| D0272 |
Bitewings - two radiographic images |
101 |
100 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$870.00 |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$583.20 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$576.00 |