| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
290 |
286 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
417 |
417 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
193 |
189 |
$9K |
| D1120 |
Prophylaxis - child |
170 |
170 |
$5K |
| D9430 |
|
135 |
122 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
342 |
324 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
73 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
548 |
273 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
178 |
178 |
$2K |
| D9110 |
|
14 |
13 |
$882.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$237.60 |