| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
701 |
700 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
608 |
608 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
540 |
537 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,442 |
793 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,164 |
1,163 |
$14K |
| D1120 |
Prophylaxis - child |
362 |
362 |
$10K |
| D0274 |
Bitewings - four radiographic images |
502 |
501 |
$10K |
| D0330 |
Panoramic radiographic image |
71 |
71 |
$2K |
| D0350 |
|
128 |
53 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$576.00 |