| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
701 |
699 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,089 |
1,089 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
541 |
539 |
$32K |
| D1120 |
Prophylaxis - child |
637 |
636 |
$19K |
| D0274 |
Bitewings - four radiographic images |
822 |
820 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,426 |
1,422 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,358 |
1,378 |
$13K |
| D2140 |
|
110 |
82 |
$6K |
| D9430 |
|
125 |
119 |
$4K |
| D0272 |
Bitewings - two radiographic images |
92 |
92 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
37 |
37 |
$418.00 |