| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
185 |
185 |
$6K |
| D1120 |
Prophylaxis - child |
63 |
63 |
$3K |
| D1110 |
Prophylaxis - adult |
45 |
45 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$1K |
| D1206 |
Topical application of fluoride varnish |
34 |
34 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
32 |
$800.00 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$585.00 |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$468.00 |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
54 |
$270.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
31 |
31 |
$156.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$140.00 |