| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
881 |
879 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
696 |
695 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
303 |
303 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
178 |
178 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
924 |
685 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
794 |
792 |
$3K |
| D0274 |
Bitewings - four radiographic images |
290 |
290 |
$3K |
| D1120 |
Prophylaxis - child |
58 |
58 |
$812.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
42 |
42 |
$420.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$168.00 |