| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
94 |
94 |
$2K |
| D1206 |
Topical application of fluoride varnish |
59 |
59 |
$1K |
| D1110 |
Prophylaxis - adult |
30 |
30 |
$961.24 |
| D1999 |
|
84 |
72 |
$820.01 |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
32 |
$576.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$312.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$264.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$190.00 |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
31 |
$169.46 |
| D0230 |
Intraoral - periapical each additional radiographic image |
29 |
29 |
$130.82 |