| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
364 |
364 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
518 |
517 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
450 |
450 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
380 |
380 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
46 |
46 |
$2K |
| D0272 |
Bitewings - two radiographic images |
128 |
128 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
126 |
126 |
$2K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$516.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$377.00 |