| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
349 |
348 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
432 |
431 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
106 |
105 |
$2K |
| D1120 |
Prophylaxis - child |
58 |
58 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
473 |
471 |
$2K |
| D0274 |
Bitewings - four radiographic images |
204 |
201 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
393 |
390 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
58 |
58 |
$1K |
| D9920 |
|
21 |
20 |
$525.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$90.00 |
| D1330 |
|
655 |
637 |
$0.00 |