| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
161 |
130 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
202 |
160 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
89 |
81 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
85 |
51 |
$2K |
| D1206 |
Topical application of fluoride varnish |
153 |
122 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
81 |
43 |
$568.40 |
| D0330 |
Panoramic radiographic image |
77 |
56 |
$301.75 |
| D0274 |
Bitewings - four radiographic images |
24 |
12 |
$234.85 |
| D1120 |
Prophylaxis - child |
18 |
18 |
$0.00 |
| D4355 |
|
13 |
12 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
53 |
49 |
$0.00 |