| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
95 |
93 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
134 |
132 |
$3K |
| D0330 |
Panoramic radiographic image |
55 |
54 |
$2K |
| D1120 |
Prophylaxis - child |
40 |
38 |
$2K |
| D0274 |
Bitewings - four radiographic images |
75 |
74 |
$2K |
| D0272 |
Bitewings - two radiographic images |
63 |
61 |
$964.46 |
| D0220 |
Intraoral - periapical first radiographic image |
122 |
120 |
$755.32 |
| D0230 |
Intraoral - periapical each additional radiographic image |
130 |
54 |
$489.51 |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
30 |
$425.70 |