| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,117 |
1,059 |
$19K |
| D1120 |
Prophylaxis - child |
630 |
585 |
$14K |
| D1110 |
Prophylaxis - adult |
388 |
380 |
$14K |
| D1206 |
Topical application of fluoride varnish |
322 |
307 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
182 |
177 |
$4K |
| D0274 |
Bitewings - four radiographic images |
126 |
126 |
$3K |
| D0272 |
Bitewings - two radiographic images |
128 |
119 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
157 |
139 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
44 |
40 |
$845.07 |
| D0220 |
Intraoral - periapical first radiographic image |
35 |
28 |
$273.75 |