| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
42 |
42 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
62 |
62 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
20 |
20 |
$912.00 |
| D1120 |
Prophylaxis - child |
23 |
23 |
$764.75 |
| D0230 |
Intraoral - periapical each additional radiographic image |
48 |
47 |
$592.80 |
| D0274 |
Bitewings - four radiographic images |
20 |
20 |
$480.70 |
| D1208 |
Topical application of fluoride, excluding varnish |
35 |
35 |
$432.25 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$199.50 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$172.90 |