| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
490 |
490 |
$21K |
| D1206 |
Topical application of fluoride varnish |
310 |
310 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
374 |
374 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
486 |
480 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
378 |
376 |
$2K |
| D0191 |
|
71 |
63 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
31 |
$1K |
| D0274 |
Bitewings - four radiographic images |
113 |
112 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
44 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$465.00 |
| D0272 |
Bitewings - two radiographic images |
44 |
44 |
$440.00 |
| D0350 |
|
16 |
16 |
$80.00 |