| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
155 |
155 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
156 |
156 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
88 |
88 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
85 |
85 |
$1K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$945.00 |
| D0140 |
Limited oral evaluation - problem focused |
50 |
50 |
$945.00 |
| D0210 |
Intraoral - complete series of radiographic images |
34 |
34 |
$540.00 |
| D0274 |
Bitewings - four radiographic images |
46 |
46 |
$228.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$160.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$20.00 |