| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
699 |
694 |
$12K |
| D1120 |
Prophylaxis - child |
479 |
479 |
$10K |
| D1110 |
Prophylaxis - adult |
281 |
275 |
$10K |
| D1206 |
Topical application of fluoride varnish |
593 |
589 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
172 |
170 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
115 |
114 |
$3K |
| D0274 |
Bitewings - four radiographic images |
94 |
89 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$535.04 |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
29 |
$441.00 |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
69 |
$367.50 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$273.00 |