| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
142 |
142 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
178 |
178 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
168 |
168 |
$2K |
| D0274 |
Bitewings - four radiographic images |
115 |
115 |
$2K |
| D1120 |
Prophylaxis - child |
95 |
95 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
30 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
75 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
244 |
119 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
131 |
128 |
$655.75 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$125.00 |