| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,115 |
1,110 |
$68K |
| D1110 |
Prophylaxis - adult |
410 |
409 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
476 |
474 |
$29K |
| D1120 |
Prophylaxis - child |
581 |
580 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,550 |
1,366 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
695 |
679 |
$8K |
| D0272 |
Bitewings - two radiographic images |
389 |
389 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
243 |
242 |
$4K |
| D1206 |
Topical application of fluoride varnish |
240 |
240 |
$2K |
| D9430 |
|
14 |
14 |
$448.00 |
| D0350 |
|
21 |
15 |
$259.20 |