| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
34 |
34 |
$900.00 |
| D0210 |
Intraoral - complete series of radiographic images |
23 |
23 |
$840.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$735.00 |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$590.00 |
| D0120 |
Periodic oral evaluation - established patient |
32 |
32 |
$462.00 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$250.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
33 |
33 |
$236.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
56 |
30 |
$169.00 |
| D1206 |
Topical application of fluoride varnish |
17 |
17 |
$84.00 |