| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
460 |
453 |
$11K |
| D1110 |
Prophylaxis - adult |
283 |
279 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
517 |
511 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
662 |
646 |
$6K |
| D0274 |
Bitewings - four radiographic images |
291 |
288 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
634 |
609 |
$5K |
| D1120 |
Prophylaxis - child |
211 |
211 |
$5K |
| D0272 |
Bitewings - two radiographic images |
156 |
156 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
22 |
21 |
$720.00 |