| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
406 |
366 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
196 |
176 |
$7K |
| D1206 |
Topical application of fluoride varnish |
243 |
216 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
141 |
131 |
$4K |
| D0330 |
Panoramic radiographic image |
44 |
43 |
$2K |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
43 |
$910.66 |
| D0220 |
Intraoral - periapical first radiographic image |
66 |
63 |
$688.40 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
14 |
$490.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
19 |
$164.40 |
| D1999 |
|
404 |
354 |
$0.00 |