| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
277 |
277 |
$7K |
| D1120 |
Prophylaxis - child |
200 |
200 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
85 |
85 |
$4K |
| D9999 |
Unspecified adjunctive procedure, by report |
26 |
26 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
63 |
63 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
50 |
50 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
64 |
64 |
$570.45 |
| D0220 |
Intraoral - periapical first radiographic image |
111 |
111 |
$435.00 |
| D1310 |
|
13 |
13 |
$184.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$108.00 |
| D0601 |
|
30 |
30 |
$78.00 |
| D9993 |
|
12 |
12 |
$0.00 |