| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
170 |
165 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
79 |
79 |
$4K |
| D1110 |
Prophylaxis - adult |
102 |
100 |
$419.76 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
103 |
$200.64 |
| D1120 |
Prophylaxis - child |
17 |
17 |
$161.25 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$159.65 |
| D1330 |
|
154 |
149 |
$16.95 |
| D1208 |
Topical application of fluoride, excluding varnish |
96 |
95 |
$16.35 |
| D0274 |
Bitewings - four radiographic images |
130 |
127 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
172 |
167 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
110 |
108 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$0.00 |