| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,257 |
2,255 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
2,145 |
2,143 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,822 |
1,819 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
2,044 |
2,032 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
2,172 |
2,158 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
450 |
450 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
197 |
197 |
$4K |
| D0272 |
Bitewings - two radiographic images |
174 |
174 |
$2K |
| D1120 |
Prophylaxis - child |
37 |
37 |
$1K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$495.50 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$115.63 |