| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
27 |
27 |
$435.81 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$188.58 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
20 |
20 |
$184.01 |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
43 |
$163.38 |
| D0120 |
Periodic oral evaluation - established patient |
20 |
20 |
$132.13 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$66.62 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
17 |
$53.59 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$46.62 |
| D1330 |
|
59 |
59 |
$0.00 |