| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
732 |
617 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
232 |
232 |
$15K |
| D1110 |
Prophylaxis - adult |
64 |
64 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
65 |
65 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
95 |
95 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
711 |
323 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
124 |
124 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
101 |
100 |
$1K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$496.80 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$360.00 |
| D1330 |
|
12 |
12 |
$0.00 |