| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,062 |
1,062 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,099 |
1,099 |
$24K |
| D0274 |
Bitewings - four radiographic images |
736 |
736 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
772 |
772 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
546 |
537 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
107 |
107 |
$4K |
| D1120 |
Prophylaxis - child |
70 |
70 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$474.47 |
| D0230 |
Intraoral - periapical each additional radiographic image |
74 |
40 |
$398.32 |