| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,600 |
1,591 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
657 |
652 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
899 |
894 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
446 |
437 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
376 |
236 |
$734.25 |
| D0272 |
Bitewings - two radiographic images |
115 |
115 |
$455.00 |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$390.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
36 |
36 |
$280.00 |
| D1120 |
Prophylaxis - child |
24 |
24 |
$266.00 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$90.00 |
| D0191 |
|
13 |
13 |
$0.00 |