| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
216 |
216 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
179 |
179 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
107 |
107 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
124 |
124 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
307 |
306 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
365 |
169 |
$1K |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$572.40 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$260.00 |