| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
226 |
220 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
88 |
88 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
181 |
175 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
212 |
201 |
$3K |
| D0274 |
Bitewings - four radiographic images |
80 |
80 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
28 |
$390.00 |
| D0220 |
Intraoral - periapical first radiographic image |
57 |
51 |
$225.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
54 |
49 |
$220.00 |