| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
135 |
127 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
135 |
129 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
117 |
109 |
$3K |
| D1110 |
Prophylaxis - adult |
31 |
31 |
$1K |
| D0274 |
Bitewings - four radiographic images |
66 |
63 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
33 |
$673.60 |
| D0140 |
Limited oral evaluation - problem focused |
23 |
22 |
$356.40 |
| D0220 |
Intraoral - periapical first radiographic image |
62 |
60 |
$332.40 |
| D0272 |
Bitewings - two radiographic images |
37 |
32 |
$300.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
29 |
$167.20 |