| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
417 |
416 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
280 |
278 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
247 |
245 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,680 |
987 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,039 |
819 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
258 |
256 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
638 |
633 |
$9K |
| D0350 |
|
746 |
290 |
$7K |
| D1320 |
|
434 |
433 |
$7K |
| D9430 |
|
166 |
151 |
$5K |
| D0274 |
Bitewings - four radiographic images |
146 |
145 |
$3K |