| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
581 |
577 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
560 |
558 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
59 |
58 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
93 |
92 |
$2K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
148 |
148 |
$735.00 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$307.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$270.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
29 |
29 |
$93.00 |