| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
132 |
132 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
149 |
149 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
57 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
105 |
105 |
$1K |
| D0274 |
Bitewings - four radiographic images |
48 |
48 |
$951.76 |
| D0120 |
Periodic oral evaluation - established patient |
27 |
27 |
$547.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
75 |
75 |
$428.85 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$155.30 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$124.44 |
| 99080 |
|
22 |
12 |
$0.00 |