| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
383 |
383 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
638 |
638 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
310 |
307 |
$2K |
| D0274 |
Bitewings - four radiographic images |
67 |
67 |
$2K |
| D1206 |
Topical application of fluoride varnish |
42 |
42 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
96 |
96 |
$1K |
| D1120 |
Prophylaxis - child |
16 |
16 |
$880.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
32 |
$801.50 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$580.00 |