| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
516 |
321 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
211 |
178 |
$3K |
| D1110 |
Prophylaxis - adult |
102 |
56 |
$2K |
| D1206 |
Topical application of fluoride varnish |
196 |
85 |
$2K |
| D1120 |
Prophylaxis - child |
66 |
60 |
$2K |
| D0272 |
Bitewings - two radiographic images |
55 |
51 |
$912.00 |
| D1999 |
|
205 |
51 |
$830.00 |
| D0274 |
Bitewings - four radiographic images |
51 |
14 |
$364.40 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
13 |
$286.00 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
12 |
$132.55 |