| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,067 |
1,062 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,037 |
1,032 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
896 |
892 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,376 |
1,366 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,300 |
1,294 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
166 |
166 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
40 |
40 |
$398.56 |
| D9110 |
|
12 |
12 |
$182.10 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$27.51 |