| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
585 |
585 |
$20K |
| D1206 |
Topical application of fluoride varnish |
734 |
733 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,282 |
1,244 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
376 |
376 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
313 |
305 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
161 |
161 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
167 |
167 |
$5K |
| D0274 |
Bitewings - four radiographic images |
174 |
174 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
466 |
455 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
216 |
216 |
$3K |
| D1120 |
Prophylaxis - child |
30 |
30 |
$780.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$265.02 |
| D9985 |
|
50 |
47 |
$0.00 |