| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
102 |
102 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
119 |
119 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
65 |
65 |
$2K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$1K |
| D1206 |
Topical application of fluoride varnish |
43 |
43 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
143 |
141 |
$918.79 |
| D0274 |
Bitewings - four radiographic images |
46 |
46 |
$785.18 |
| D0140 |
Limited oral evaluation - problem focused |
34 |
33 |
$650.08 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$390.72 |
| D0230 |
Intraoral - periapical each additional radiographic image |
54 |
46 |
$255.36 |