| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
237 |
130 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
368 |
197 |
$5K |
| D1120 |
Prophylaxis - child |
268 |
140 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
300 |
159 |
$3K |
| D0272 |
Bitewings - two radiographic images |
244 |
133 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
61 |
33 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
264 |
120 |
$847.25 |
| D0220 |
Intraoral - periapical first radiographic image |
338 |
152 |
$789.41 |
| D1206 |
Topical application of fluoride varnish |
60 |
30 |
$680.12 |
| D0140 |
Limited oral evaluation - problem focused |
52 |
25 |
$360.00 |