| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
48 |
$2K |
| D1120 |
Prophylaxis - child |
29 |
29 |
$840.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
186 |
94 |
$835.24 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$520.00 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$252.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$216.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
18 |
$170.00 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$150.00 |