| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
66 |
66 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
78 |
78 |
$2K |
| D0330 |
Panoramic radiographic image |
77 |
77 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
74 |
68 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$2K |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
177 |
165 |
$2K |
| D0274 |
Bitewings - four radiographic images |
76 |
76 |
$2K |
| D1206 |
Topical application of fluoride varnish |
62 |
62 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
158 |
130 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$732.32 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$375.00 |