| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,111 |
2,104 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
2,309 |
2,303 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,461 |
1,457 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
462 |
462 |
$16K |
| D0274 |
Bitewings - four radiographic images |
1,435 |
1,429 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
2,560 |
2,399 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,093 |
2,030 |
$8K |
| D2750 |
|
17 |
12 |
$6K |
| D1120 |
Prophylaxis - child |
84 |
84 |
$2K |
| D2954 |
|
34 |
25 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$785.70 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$585.00 |