| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,479 |
1,479 |
$58K |
| D0210 |
Intraoral - complete series of radiographic images |
537 |
535 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
898 |
898 |
$19K |
| D0274 |
Bitewings - four radiographic images |
825 |
825 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
537 |
537 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,079 |
1,072 |
$10K |
| D2140 |
|
115 |
41 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
923 |
912 |
$5K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
89 |
89 |
$986.82 |
| D1999 |
|
45 |
40 |
$0.00 |