| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
778 |
776 |
$26K |
| D0274 |
Bitewings - four radiographic images |
571 |
570 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
442 |
442 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
527 |
522 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
417 |
416 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
182 |
181 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
54 |
54 |
$2K |
| D2394 |
|
18 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
40 |
40 |
$302.21 |