| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,541 |
2,520 |
$84K |
| D0120 |
Periodic oral evaluation - established patient |
2,414 |
2,402 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,018 |
1,013 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,592 |
1,501 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,697 |
1,676 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
420 |
419 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
227 |
226 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
277 |
276 |
$3K |
| D1120 |
Prophylaxis - child |
51 |
51 |
$1K |
| D9110 |
|
12 |
12 |
$168.46 |