| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,128 |
1,123 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,015 |
1,011 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
214 |
213 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
462 |
460 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
299 |
299 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
116 |
116 |
$3K |
| D0274 |
Bitewings - four radiographic images |
52 |
52 |
$1K |
| D1120 |
Prophylaxis - child |
15 |
15 |
$467.70 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$186.30 |
| D1999 |
|
71 |
67 |
$0.00 |