| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
330 |
321 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
283 |
279 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
384 |
335 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
88 |
75 |
$3K |
| D0330 |
Panoramic radiographic image |
42 |
40 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
70 |
70 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
210 |
117 |
$2K |
| D0274 |
Bitewings - four radiographic images |
42 |
40 |
$805.60 |
| D1206 |
Topical application of fluoride varnish |
27 |
27 |
$561.33 |
| D0210 |
Intraoral - complete series of radiographic images |
91 |
26 |
$418.38 |