| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
298 |
296 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
204 |
203 |
$13K |
| D0274 |
Bitewings - four radiographic images |
387 |
382 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,168 |
513 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
417 |
411 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
79 |
78 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$1K |
| D1206 |
Topical application of fluoride varnish |
51 |
51 |
$768.50 |
| D0350 |
|
51 |
21 |
$364.80 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$360.00 |
| D1330 |
|
65 |
64 |
$0.00 |