| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
790 |
790 |
$20K |
| D1120 |
Prophylaxis - child |
434 |
434 |
$16K |
| D1110 |
Prophylaxis - adult |
325 |
325 |
$16K |
| D1206 |
Topical application of fluoride varnish |
383 |
383 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
109 |
109 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$1K |
| D0272 |
Bitewings - two radiographic images |
50 |
50 |
$1K |
| D0274 |
Bitewings - four radiographic images |
32 |
32 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$857.45 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
39 |
$525.78 |