| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
358 |
347 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
407 |
391 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
207 |
177 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
282 |
245 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
257 |
184 |
$3K |
| D1120 |
Prophylaxis - child |
46 |
46 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
74 |
73 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
39 |
$2K |
| D0274 |
Bitewings - four radiographic images |
35 |
32 |
$1K |
| D9110 |
|
26 |
25 |
$900.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$866.00 |
| D0180 |
|
15 |
15 |
$576.00 |