| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
421 |
409 |
$9K |
| D1206 |
Topical application of fluoride varnish |
400 |
387 |
$7K |
| D1110 |
Prophylaxis - adult |
138 |
135 |
$5K |
| D1120 |
Prophylaxis - child |
126 |
120 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
136 |
132 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
51 |
51 |
$587.42 |
| D0230 |
Intraoral - periapical each additional radiographic image |
58 |
30 |
$470.50 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$374.92 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$117.00 |
| D1999 |
|
32 |
31 |
$0.00 |