| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,738 |
1,715 |
$92K |
| D0274 |
Bitewings - four radiographic images |
857 |
842 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,198 |
1,192 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,651 |
1,597 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,051 |
947 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
342 |
328 |
$13K |
| D0330 |
Panoramic radiographic image |
50 |
50 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
28 |
$488.00 |