| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
317 |
317 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
721 |
707 |
$9K |
| D1110 |
Prophylaxis - adult |
165 |
165 |
$8K |
| D1206 |
Topical application of fluoride varnish |
486 |
486 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
336 |
336 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
124 |
124 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
337 |
266 |
$4K |
| D0274 |
Bitewings - four radiographic images |
135 |
135 |
$3K |
| D0272 |
Bitewings - two radiographic images |
181 |
181 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
63 |
63 |
$2K |