| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
295 |
294 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
509 |
507 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
120 |
120 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
60 |
58 |
$3K |
| D1206 |
Topical application of fluoride varnish |
72 |
72 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
230 |
225 |
$2K |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$840.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
39 |
$483.00 |
| D9995 |
|
13 |
13 |
$320.00 |