| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
410 |
383 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
570 |
524 |
$9K |
| D1206 |
Topical application of fluoride varnish |
278 |
254 |
$4K |
| D0274 |
Bitewings - four radiographic images |
62 |
59 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$504.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
42 |
16 |
$348.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$310.50 |
| D0220 |
Intraoral - periapical first radiographic image |
20 |
17 |
$213.36 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$0.00 |
| D1999 |
|
56 |
52 |
$0.00 |