| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
273 |
273 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
361 |
361 |
$10K |
| D1120 |
Prophylaxis - child |
93 |
93 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
77 |
77 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
63 |
63 |
$882.00 |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$840.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$810.00 |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$696.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$91.00 |