| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
588 |
588 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
834 |
834 |
$21K |
| D1110 |
Prophylaxis - adult |
423 |
423 |
$20K |
| D1206 |
Topical application of fluoride varnish |
692 |
692 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
180 |
178 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
48 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
40 |
$2K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
25 |
13 |
$183.00 |