| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
834 |
822 |
$17K |
| D1110 |
Prophylaxis - adult |
402 |
401 |
$13K |
| D1206 |
Topical application of fluoride varnish |
227 |
226 |
$5K |
| D1120 |
Prophylaxis - child |
187 |
186 |
$4K |
| D0274 |
Bitewings - four radiographic images |
116 |
116 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
89 |
77 |
$599.40 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$578.10 |
| D1208 |
Topical application of fluoride, excluding varnish |
95 |
95 |
$505.70 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$364.50 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$0.00 |