| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
80 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
61 |
61 |
$5K |
| D1110 |
Prophylaxis - adult |
69 |
68 |
$182.70 |
| D1330 |
|
91 |
91 |
$68.00 |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
36 |
$48.00 |
| D0220 |
Intraoral - periapical first radiographic image |
78 |
78 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$0.00 |
| D1120 |
Prophylaxis - child |
15 |
15 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
105 |
105 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
61 |
61 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$0.00 |