| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
213 |
209 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$963.37 |
| D1208 |
Topical application of fluoride, excluding varnish |
228 |
224 |
$50.33 |
| D0274 |
Bitewings - four radiographic images |
120 |
119 |
$42.00 |
| D0220 |
Intraoral - periapical first radiographic image |
214 |
211 |
$0.00 |
| D1330 |
|
291 |
286 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
173 |
171 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
158 |
156 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
42 |
$0.00 |