| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
114 |
94 |
$1K |
| D1110 |
Prophylaxis - adult |
128 |
100 |
$616.00 |
| D0274 |
Bitewings - four radiographic images |
113 |
97 |
$270.00 |
| D1120 |
Prophylaxis - child |
17 |
17 |
$220.00 |
| D0140 |
Limited oral evaluation - problem focused |
33 |
27 |
$198.00 |
| D0220 |
Intraoral - periapical first radiographic image |
237 |
198 |
$192.00 |
| D0210 |
Intraoral - complete series of radiographic images |
49 |
43 |
$180.00 |
| D1206 |
Topical application of fluoride varnish |
18 |
18 |
$165.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
259 |
159 |
$162.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$30.00 |
| D1330 |
|
52 |
40 |
$0.00 |