| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
565 |
556 |
$16K |
| D1120 |
Prophylaxis - child |
73 |
71 |
$3K |
| D1110 |
Prophylaxis - adult |
42 |
42 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
74 |
74 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
50 |
$1K |
| D0274 |
Bitewings - four radiographic images |
65 |
65 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
122 |
122 |
$769.97 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$361.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
69 |
69 |
$304.64 |