| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
699 |
697 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
826 |
823 |
$16K |
| D0274 |
Bitewings - four radiographic images |
556 |
555 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
396 |
395 |
$3K |
| D9944 |
|
22 |
22 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
105 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
39 |
39 |
$428.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
79 |
79 |
$391.89 |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$226.20 |