| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,694 |
3,693 |
$315K |
| D9410 |
|
7,659 |
7,263 |
$214K |
| D0120 |
Periodic oral evaluation - established patient |
2,098 |
2,089 |
$180K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,518 |
2,516 |
$166K |
| D1206 |
Topical application of fluoride varnish |
3,618 |
3,617 |
$60K |
| D5120 |
|
55 |
55 |
$34K |
| D5110 |
|
41 |
41 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,064 |
788 |
$10K |
| D1120 |
Prophylaxis - child |
257 |
246 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
376 |
370 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
334 |
325 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$259.20 |