| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
196 |
196 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
189 |
189 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
161 |
161 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
163 |
163 |
$4K |
| D0330 |
Panoramic radiographic image |
146 |
146 |
$4K |
| D0274 |
Bitewings - four radiographic images |
137 |
137 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$497.28 |
| D0220 |
Intraoral - periapical first radiographic image |
75 |
73 |
$495.75 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$305.92 |
| D0230 |
Intraoral - periapical each additional radiographic image |
48 |
47 |
$215.04 |