| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
298 |
298 |
$8K |
| D1120 |
Prophylaxis - child |
277 |
277 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
259 |
259 |
$6K |
| D1206 |
Topical application of fluoride varnish |
334 |
334 |
$5K |
| D0274 |
Bitewings - four radiographic images |
185 |
185 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
106 |
106 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
192 |
185 |
$2K |
| D1110 |
Prophylaxis - adult |
32 |
32 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
55 |
$980.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
237 |
80 |
$936.00 |
| D1354 |
|
42 |
13 |
$24.00 |
| D1330 |
|
234 |
234 |
$0.00 |