| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,191 |
3,191 |
$67K |
| D1120 |
Prophylaxis - child |
2,099 |
2,099 |
$63K |
| D1110 |
Prophylaxis - adult |
975 |
975 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,746 |
1,746 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,326 |
1,326 |
$23K |
| D0272 |
Bitewings - two radiographic images |
729 |
729 |
$13K |
| D0274 |
Bitewings - four radiographic images |
270 |
270 |
$8K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
53 |
53 |
$819.48 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$359.96 |