| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
143 |
140 |
$4K |
| D1110 |
Prophylaxis - adult |
75 |
74 |
$3K |
| D1206 |
Topical application of fluoride varnish |
133 |
130 |
$2K |
| D0272 |
Bitewings - two radiographic images |
102 |
99 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
12 |
$992.97 |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$859.20 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
12 |
$376.20 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$332.43 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$239.40 |