| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
513 |
463 |
$13K |
| D1120 |
Prophylaxis - child |
241 |
216 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
144 |
138 |
$3K |
| D1110 |
Prophylaxis - adult |
60 |
51 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
417 |
372 |
$2K |
| D0274 |
Bitewings - four radiographic images |
64 |
56 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
26 |
$782.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
134 |
123 |
$714.40 |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
18 |
$468.00 |