| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
687 |
687 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
661 |
660 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
852 |
850 |
$8K |
| D0274 |
Bitewings - four radiographic images |
421 |
421 |
$7K |
| D0330 |
Panoramic radiographic image |
196 |
195 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
563 |
560 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
47 |
$960.90 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$184.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$124.14 |