| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
443 |
435 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
475 |
431 |
$6K |
| D1110 |
Prophylaxis - adult |
138 |
134 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
64 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
216 |
120 |
$2K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
31 |
31 |
$743.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$478.67 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$325.00 |
| D1999 |
|
15 |
14 |
$0.00 |