| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,067 |
1,067 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,178 |
1,178 |
$17K |
| D1110 |
Prophylaxis - adult |
422 |
422 |
$17K |
| D1120 |
Prophylaxis - child |
630 |
629 |
$16K |
| D0274 |
Bitewings - four radiographic images |
583 |
583 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
299 |
299 |
$10K |
| D1206 |
Topical application of fluoride varnish |
321 |
321 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
576 |
540 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
734 |
270 |
$6K |
| D4355 |
|
176 |
99 |
$6K |
| D0330 |
Panoramic radiographic image |
47 |
47 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$449.28 |