| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,630 |
1,821 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
2,014 |
1,423 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,884 |
1,337 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
825 |
534 |
$20K |
| D0274 |
Bitewings - four radiographic images |
760 |
567 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
48 |
$2K |
| D1110 |
Prophylaxis - adult |
138 |
100 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
122 |
90 |
$999.40 |
| D0272 |
Bitewings - two radiographic images |
30 |
25 |
$474.35 |
| D1206 |
Topical application of fluoride varnish |
19 |
15 |
$386.68 |
| D1999 |
|
832 |
662 |
$0.00 |