| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
150 |
150 |
$5K |
| D1120 |
Prophylaxis - child |
87 |
87 |
$4K |
| D1110 |
Prophylaxis - adult |
53 |
53 |
$3K |
| D1206 |
Topical application of fluoride varnish |
100 |
100 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
200 |
197 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
34 |
33 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
161 |
156 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
36 |
36 |
$1K |
| D0272 |
Bitewings - two radiographic images |
41 |
41 |
$1K |
| D0274 |
Bitewings - four radiographic images |
32 |
32 |
$573.36 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$325.04 |