| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,700 |
1,699 |
$66K |
| D0274 |
Bitewings - four radiographic images |
1,461 |
1,460 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,404 |
1,404 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
1,677 |
1,667 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,602 |
1,598 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
306 |
305 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
169 |
169 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
485 |
484 |
$5K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$833.53 |