| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
185 |
185 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
223 |
223 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
57 |
$6K |
| D0274 |
Bitewings - four radiographic images |
313 |
311 |
$334.36 |
| D1208 |
Topical application of fluoride, excluding varnish |
385 |
383 |
$94.74 |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$79.21 |
| D0220 |
Intraoral - periapical first radiographic image |
395 |
385 |
$25.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
366 |
363 |
$0.00 |
| D1330 |
|
370 |
368 |
$0.00 |
| D0601 |
|
14 |
14 |
$0.00 |
| D1120 |
Prophylaxis - child |
31 |
30 |
$0.00 |