| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,805 |
1,805 |
$35K |
| D1110 |
Prophylaxis - adult |
927 |
927 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
2,039 |
2,034 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,719 |
1,719 |
$20K |
| D1120 |
Prophylaxis - child |
659 |
659 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,947 |
1,946 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
608 |
608 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
163 |
163 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
53 |
52 |
$2K |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$180.00 |