| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,555 |
2,554 |
$200K |
| D9410 |
|
7,074 |
6,753 |
$196K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,504 |
1,503 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
1,774 |
1,774 |
$74K |
| D1206 |
Topical application of fluoride varnish |
2,379 |
2,379 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,246 |
650 |
$14K |
| D5120 |
|
16 |
16 |
$10K |
| D5110 |
|
14 |
14 |
$9K |
| D5750 |
|
44 |
44 |
$8K |
| D0274 |
Bitewings - four radiographic images |
276 |
276 |
$5K |
| D1120 |
Prophylaxis - child |
145 |
145 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
270 |
270 |
$3K |
| D5751 |
|
14 |
14 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
146 |
146 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$570.00 |
| D1330 |
|
209 |
208 |
$0.00 |