| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,654 |
1,654 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,479 |
1,479 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,293 |
1,233 |
$9K |
| D0274 |
Bitewings - four radiographic images |
327 |
327 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
551 |
528 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
46 |
46 |
$828.62 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$419.25 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$159.45 |
| D0431 |
|
295 |
295 |
$0.00 |