| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
349 |
349 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
130 |
130 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
205 |
205 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
290 |
290 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
330 |
329 |
$2K |
| D0274 |
Bitewings - four radiographic images |
245 |
245 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
103 |
103 |
$458.26 |
| D1120 |
Prophylaxis - child |
27 |
27 |
$438.89 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$124.83 |