| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
79 |
79 |
$1K |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$858.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
120 |
69 |
$777.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$484.82 |
| D0220 |
Intraoral - periapical first radiographic image |
74 |
73 |
$420.00 |
| D0120 |
Periodic oral evaluation - established patient |
99 |
67 |
$310.00 |
| D1330 |
|
35 |
34 |
$0.00 |
| D0602 |
|
26 |
26 |
$0.00 |
| D0603 |
|
12 |
12 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$0.00 |
| T1015 |
Clinic visit/encounter, all-inclusive |
54 |
48 |
$0.00 |