| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
992 |
991 |
$22K |
| D1110 |
Prophylaxis - adult |
583 |
583 |
$20K |
| D1120 |
Prophylaxis - child |
535 |
531 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
605 |
602 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
376 |
351 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
967 |
913 |
$10K |
| D0274 |
Bitewings - four radiographic images |
247 |
247 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
734 |
666 |
$5K |
| D0272 |
Bitewings - two radiographic images |
72 |
72 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$936.26 |