| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
197 |
197 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
16 |
15 |
$990.85 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$259.52 |
| D0120 |
Periodic oral evaluation - established patient |
269 |
268 |
$100.45 |
| D0274 |
Bitewings - four radiographic images |
100 |
100 |
$43.06 |
| D0220 |
Intraoral - periapical first radiographic image |
211 |
206 |
$9.22 |
| D1208 |
Topical application of fluoride, excluding varnish |
250 |
249 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
168 |
159 |
$0.00 |