| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
497 |
497 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
906 |
905 |
$36K |
| D1120 |
Prophylaxis - child |
520 |
518 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,141 |
1,140 |
$12K |
| D0274 |
Bitewings - four radiographic images |
439 |
439 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
184 |
184 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
113 |
112 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
958 |
354 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
27 |
$270.00 |