| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
908 |
905 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,286 |
1,280 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
610 |
608 |
$17K |
| D0170 |
|
310 |
306 |
$8K |
| D0274 |
Bitewings - four radiographic images |
174 |
173 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
481 |
478 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
96 |
96 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
892 |
369 |
$3K |
| D4910 |
|
46 |
46 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
44 |
$3K |
| D0602 |
|
62 |
62 |
$682.00 |
| D0603 |
|
62 |
61 |
$660.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$520.00 |
| D0601 |
|
13 |
13 |
$143.00 |
| D1330 |
|
15 |
15 |
$130.00 |