| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
228 |
228 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
230 |
230 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
81 |
81 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
111 |
111 |
$2K |
| D1120 |
Prophylaxis - child |
95 |
95 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
211 |
210 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
280 |
278 |
$1K |
| D0272 |
Bitewings - two radiographic images |
130 |
130 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
35 |
35 |
$525.00 |
| D1330 |
|
408 |
402 |
$0.00 |