| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
140 |
137 |
$4K |
| D1110 |
Prophylaxis - adult |
86 |
85 |
$4K |
| D1120 |
Prophylaxis - child |
53 |
53 |
$2K |
| D0330 |
Panoramic radiographic image |
20 |
20 |
$880.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$765.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
30 |
$750.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$375.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$275.00 |
| D0220 |
Intraoral - periapical first radiographic image |
45 |
45 |
$170.00 |