| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
822 |
811 |
$9K |
| D1110 |
Prophylaxis - adult |
551 |
548 |
$7K |
| D0274 |
Bitewings - four radiographic images |
413 |
413 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
926 |
788 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
879 |
870 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
168 |
168 |
$1K |
| D1120 |
Prophylaxis - child |
99 |
99 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
97 |
$655.00 |
| D0210 |
Intraoral - complete series of radiographic images |
73 |
73 |
$528.25 |