| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
517 |
513 |
$19K |
| D0274 |
Bitewings - four radiographic images |
319 |
318 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
296 |
296 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
364 |
359 |
$6K |
| D1120 |
Prophylaxis - child |
201 |
200 |
$6K |
| D0330 |
Panoramic radiographic image |
198 |
197 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
132 |
130 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
62 |
62 |
$598.87 |
| D0272 |
Bitewings - two radiographic images |
28 |
27 |
$433.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
12 |
$117.00 |