| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
122 |
122 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
130 |
128 |
$3K |
| D1120 |
Prophylaxis - child |
60 |
60 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
54 |
54 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
44 |
$1K |
| D0274 |
Bitewings - four radiographic images |
68 |
68 |
$792.00 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$585.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$540.00 |
| D0220 |
Intraoral - periapical first radiographic image |
97 |
97 |
$480.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
83 |
82 |
$468.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$406.25 |
| D1330 |
|
246 |
244 |
$0.00 |