| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
254 |
254 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
112 |
112 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
50 |
50 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
519 |
212 |
$2K |
| D1206 |
Topical application of fluoride varnish |
115 |
115 |
$2K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$1K |
| D0272 |
Bitewings - two radiographic images |
81 |
80 |
$908.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
39 |
39 |
$544.25 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
13 |
$168.00 |