| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
497 |
497 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
153 |
153 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
290 |
288 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
112 |
112 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$2K |
| D0274 |
Bitewings - four radiographic images |
38 |
38 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$780.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
28 |
$378.00 |