| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
276 |
274 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
246 |
244 |
$5K |
| D0272 |
Bitewings - two radiographic images |
79 |
79 |
$892.81 |
| D0220 |
Intraoral - periapical first radiographic image |
79 |
78 |
$735.68 |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$724.76 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
21 |
21 |
$435.50 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$333.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$244.90 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$156.60 |