| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
364 |
333 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
450 |
412 |
$10K |
| D1120 |
Prophylaxis - child |
119 |
108 |
$5K |
| D0274 |
Bitewings - four radiographic images |
138 |
128 |
$5K |
| D1206 |
Topical application of fluoride varnish |
134 |
126 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
170 |
152 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
27 |
$918.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
49 |
43 |
$596.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$348.00 |
| D0601 |
|
41 |
40 |
$0.00 |
| D0603 |
|
88 |
85 |
$0.00 |
| D1330 |
|
14 |
14 |
$0.00 |