| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
451 |
451 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
204 |
200 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
382 |
378 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
135 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
78 |
78 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
485 |
468 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
626 |
345 |
$2K |
| D0274 |
Bitewings - four radiographic images |
125 |
124 |
$1K |