| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
350 |
342 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
662 |
599 |
$17K |
| D1120 |
Prophylaxis - child |
167 |
143 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
77 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
180 |
166 |
$3K |
| D0272 |
Bitewings - two radiographic images |
97 |
77 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
224 |
48 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
74 |
68 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$500.50 |