| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
595 |
593 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
608 |
607 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
182 |
182 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
122 |
121 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
65 |
65 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
175 |
175 |
$2K |
| D1120 |
Prophylaxis - child |
112 |
112 |
$2K |
| D2954 |
|
17 |
13 |
$767.20 |
| D0220 |
Intraoral - periapical first radiographic image |
167 |
166 |
$642.45 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$200.70 |
| D9110 |
|
13 |
12 |
$133.20 |