| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
700 |
694 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,080 |
1,063 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
734 |
724 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
243 |
242 |
$13K |
| D0274 |
Bitewings - four radiographic images |
561 |
551 |
$13K |
| D1120 |
Prophylaxis - child |
255 |
249 |
$12K |
| D0330 |
Panoramic radiographic image |
70 |
69 |
$3K |
| D1330 |
|
251 |
245 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
149 |
143 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
35 |
35 |
$340.96 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$196.92 |