| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
586 |
585 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
748 |
745 |
$13K |
| D1120 |
Prophylaxis - child |
120 |
120 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
308 |
305 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
130 |
130 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
55 |
55 |
$1K |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$977.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
123 |
123 |
$600.40 |
| D0272 |
Bitewings - two radiographic images |
51 |
51 |
$500.10 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$310.50 |