| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
668 |
665 |
$27K |
| D1120 |
Prophylaxis - child |
512 |
508 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
913 |
223 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
48 |
$2K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
211 |
183 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$514.00 |
| D0274 |
Bitewings - four radiographic images |
42 |
42 |
$428.40 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$140.00 |
| D1999 |
|
437 |
412 |
$90.00 |