| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
39 |
39 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
59 |
57 |
$967.45 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
36 |
$686.47 |
| D1206 |
Topical application of fluoride varnish |
24 |
24 |
$369.75 |
| D0330 |
Panoramic radiographic image |
15 |
14 |
$335.84 |
| D0220 |
Intraoral - periapical first radiographic image |
65 |
62 |
$227.50 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$184.03 |
| D0274 |
Bitewings - four radiographic images |
19 |
18 |
$163.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
34 |
18 |
$57.00 |
| D1999 |
|
229 |
193 |
$0.00 |