| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
861 |
860 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,379 |
1,020 |
$21K |
| D1120 |
Prophylaxis - child |
517 |
516 |
$16K |
| D1110 |
Prophylaxis - adult |
146 |
145 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,129 |
1,125 |
$12K |
| D0272 |
Bitewings - two radiographic images |
804 |
803 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
63 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$237.60 |