| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
991 |
946 |
$27K |
| D1120 |
Prophylaxis - child |
281 |
261 |
$11K |
| D1110 |
Prophylaxis - adult |
155 |
151 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
194 |
187 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
135 |
131 |
$3K |
| D0274 |
Bitewings - four radiographic images |
144 |
137 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
135 |
135 |
$892.35 |
| D0230 |
Intraoral - periapical each additional radiographic image |
78 |
78 |
$613.77 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$591.64 |