| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
88 |
88 |
$731.85 |
| D0120 |
Periodic oral evaluation - established patient |
98 |
98 |
$525.00 |
| D1206 |
Topical application of fluoride varnish |
132 |
132 |
$382.20 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
86 |
$130.40 |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$71.04 |
| D0220 |
Intraoral - periapical first radiographic image |
160 |
158 |
$26.44 |
| D0230 |
Intraoral - periapical each additional radiographic image |
81 |
81 |
$8.96 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$0.00 |