| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,205 |
1,204 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
904 |
904 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
998 |
997 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,245 |
1,244 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,177 |
1,169 |
$10K |
| D0274 |
Bitewings - four radiographic images |
333 |
333 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
218 |
218 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
86 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
42 |
42 |
$442.40 |