| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
790 |
789 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
812 |
810 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
597 |
587 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
500 |
499 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
237 |
235 |
$3K |
| D0274 |
Bitewings - four radiographic images |
49 |
49 |
$1K |
| D1120 |
Prophylaxis - child |
30 |
30 |
$915.87 |
| D0140 |
Limited oral evaluation - problem focused |
77 |
70 |
$869.65 |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
30 |
$302.90 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$288.32 |
| D1999 |
|
34 |
31 |
$0.00 |