| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
576 |
575 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
792 |
790 |
$8K |
| D0272 |
Bitewings - two radiographic images |
485 |
485 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
668 |
665 |
$3K |
| D0330 |
Panoramic radiographic image |
84 |
84 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
300 |
300 |
$750.64 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$340.75 |
| D1120 |
Prophylaxis - child |
16 |
16 |
$279.10 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$84.46 |