| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
704 |
704 |
$13K |
| D1120 |
Prophylaxis - child |
367 |
367 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,063 |
1,050 |
$4K |
| D0274 |
Bitewings - four radiographic images |
304 |
304 |
$3K |
| D1110 |
Prophylaxis - adult |
136 |
136 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
590 |
590 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
267 |
267 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
61 |
58 |
$1K |
| D1206 |
Topical application of fluoride varnish |
27 |
27 |
$202.50 |
| D0272 |
Bitewings - two radiographic images |
31 |
31 |
$125.00 |