| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
371 |
371 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
233 |
233 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
169 |
169 |
$11K |
| D4910 |
|
109 |
109 |
$8K |
| D9430 |
|
245 |
234 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
354 |
354 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
116 |
116 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
745 |
252 |
$3K |
| D1206 |
Topical application of fluoride varnish |
56 |
55 |
$967.00 |
| D9993 |
|
12 |
12 |
$698.75 |
| D0350 |
|
62 |
26 |
$604.80 |
| D1310 |
|
12 |
12 |
$475.25 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$259.20 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$204.00 |