| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
135 |
135 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
176 |
176 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
37 |
37 |
$722.88 |
| D0230 |
Intraoral - periapical each additional radiographic image |
94 |
94 |
$602.69 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$507.58 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$350.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$168.00 |