| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,159 |
1,158 |
$96K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,950 |
1,260 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,749 |
1,746 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
373 |
373 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
291 |
291 |
$13K |
| D0272 |
Bitewings - two radiographic images |
1,021 |
1,019 |
$12K |
| D1120 |
Prophylaxis - child |
371 |
371 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
145 |
145 |
$8K |
| D4910 |
|
48 |
48 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
231 |
228 |
$3K |