| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
149 |
149 |
$8K |
| D1120 |
Prophylaxis - child |
106 |
106 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
103 |
103 |
$3K |
| D0330 |
Panoramic radiographic image |
67 |
67 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
83 |
83 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
155 |
155 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$181.42 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$168.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$140.00 |