| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
219 |
219 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
239 |
239 |
$7K |
| D0274 |
Bitewings - four radiographic images |
179 |
179 |
$2K |
| D1120 |
Prophylaxis - child |
47 |
47 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
48 |
48 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
86 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
309 |
303 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
80 |
76 |
$960.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
195 |
195 |
$771.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$400.00 |
| D0272 |
Bitewings - two radiographic images |
31 |
31 |
$310.00 |