| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
188 |
188 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
53 |
53 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
58 |
$853.12 |
| D0140 |
Limited oral evaluation - problem focused |
156 |
156 |
$850.15 |
| D0274 |
Bitewings - four radiographic images |
227 |
227 |
$757.10 |
| D0220 |
Intraoral - periapical first radiographic image |
360 |
353 |
$92.05 |
| D0120 |
Periodic oral evaluation - established patient |
66 |
66 |
$19.24 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
127 |
125 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
60 |
60 |
$0.00 |