| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
112 |
66 |
$1K |
| D0274 |
Bitewings - four radiographic images |
141 |
80 |
$993.72 |
| D0220 |
Intraoral - periapical first radiographic image |
254 |
136 |
$715.83 |
| D0120 |
Periodic oral evaluation - established patient |
110 |
59 |
$605.46 |
| D0230 |
Intraoral - periapical each additional radiographic image |
264 |
115 |
$564.68 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
13 |
$266.67 |
| D0140 |
Limited oral evaluation - problem focused |
63 |
28 |
$249.39 |
| D1208 |
Topical application of fluoride, excluding varnish |
51 |
25 |
$194.47 |
| D0272 |
Bitewings - two radiographic images |
34 |
12 |
$26.78 |
| D1999 |
|
70 |
51 |
$0.00 |