| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
496 |
496 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
703 |
700 |
$16K |
| D0274 |
Bitewings - four radiographic images |
442 |
440 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
257 |
257 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
79 |
$2K |
| D0330 |
Panoramic radiographic image |
47 |
47 |
$2K |
| D1120 |
Prophylaxis - child |
31 |
31 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
67 |
67 |
$765.14 |
| D0230 |
Intraoral - periapical each additional radiographic image |
46 |
46 |
$596.14 |
| D0210 |
Intraoral - complete series of radiographic images |
46 |
46 |
$172.02 |