| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
368 |
366 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
403 |
403 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
186 |
182 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
204 |
204 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
527 |
522 |
$7K |
| D4910 |
|
82 |
81 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,254 |
210 |
$5K |
| D0274 |
Bitewings - four radiographic images |
122 |
118 |
$3K |
| D9430 |
|
40 |
36 |
$1K |
| D1206 |
Topical application of fluoride varnish |
51 |
51 |
$878.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$682.50 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |