| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
828 |
825 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
1,045 |
1,043 |
$59K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,279 |
1,263 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
114 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
440 |
440 |
$5K |
| D1206 |
Topical application of fluoride varnish |
258 |
257 |
$5K |
| D1120 |
Prophylaxis - child |
139 |
139 |
$4K |
| D0272 |
Bitewings - two radiographic images |
384 |
383 |
$4K |
| D0274 |
Bitewings - four radiographic images |
185 |
184 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$624.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$120.00 |