| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,290 |
1,290 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,231 |
1,190 |
$25K |
| D1120 |
Prophylaxis - child |
745 |
745 |
$19K |
| D1110 |
Prophylaxis - adult |
329 |
329 |
$10K |
| D0272 |
Bitewings - two radiographic images |
191 |
191 |
$2K |
| D1206 |
Topical application of fluoride varnish |
34 |
34 |
$820.59 |
| D0140 |
Limited oral evaluation - problem focused |
32 |
32 |
$732.48 |
| D1999 |
|
61 |
54 |
$610.00 |
| D0274 |
Bitewings - four radiographic images |
36 |
36 |
$609.36 |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$484.66 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$67.32 |