| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
547 |
543 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
405 |
401 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
225 |
219 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
212 |
212 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
282 |
172 |
$764.06 |
| D0220 |
Intraoral - periapical first radiographic image |
199 |
195 |
$302.77 |
| D1206 |
Topical application of fluoride varnish |
55 |
55 |
$110.16 |
| D0330 |
Panoramic radiographic image |
59 |
59 |
$89.68 |
| D0272 |
Bitewings - two radiographic images |
54 |
54 |
$87.67 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$0.00 |