| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
408 |
397 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
619 |
602 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
476 |
460 |
$11K |
| D1120 |
Prophylaxis - child |
253 |
245 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
125 |
123 |
$7K |
| D0274 |
Bitewings - four radiographic images |
229 |
221 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
168 |
165 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
67 |
65 |
$760.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
77 |
39 |
$725.36 |
| D0272 |
Bitewings - two radiographic images |
27 |
26 |
$444.72 |