| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
617 |
617 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
556 |
556 |
$13K |
| D1206 |
Topical application of fluoride varnish |
377 |
377 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
224 |
224 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
163 |
161 |
$5K |
| D0274 |
Bitewings - four radiographic images |
330 |
330 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
762 |
709 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
51 |
51 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
478 |
468 |
$2K |
| D9920 |
|
59 |
59 |
$1K |
| D1120 |
Prophylaxis - child |
14 |
14 |
$422.50 |
| D0603 |
|
24 |
24 |
$170.00 |