| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
437 |
428 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
446 |
435 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
430 |
415 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
239 |
236 |
$9K |
| D0274 |
Bitewings - four radiographic images |
306 |
299 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
260 |
254 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
604 |
583 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
96 |
96 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
81 |
81 |
$900.33 |
| D1120 |
Prophylaxis - child |
25 |
25 |
$747.90 |