| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
764 |
759 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
511 |
508 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
589 |
585 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
166 |
165 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
442 |
241 |
$4K |
| D0274 |
Bitewings - four radiographic images |
69 |
68 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$312.00 |