| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,142 |
3,142 |
$132K |
| D0120 |
Periodic oral evaluation - established patient |
4,337 |
4,337 |
$118K |
| D1110 |
Prophylaxis - adult |
1,382 |
1,382 |
$76K |
| D1206 |
Topical application of fluoride varnish |
1,720 |
1,720 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,222 |
2,222 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,044 |
1,044 |
$29K |
| D0330 |
Panoramic radiographic image |
589 |
589 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,205 |
1,205 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
479 |
479 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$556.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$182.00 |