| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,092 |
2,091 |
$82K |
| D0120 |
Periodic oral evaluation - established patient |
1,955 |
1,954 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,728 |
1,728 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
1,982 |
1,977 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,748 |
1,745 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
243 |
243 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
115 |
115 |
$4K |
| D1120 |
Prophylaxis - child |
15 |
14 |
$453.95 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
14 |
$155.50 |