| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
442 |
383 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
508 |
442 |
$8K |
| D0274 |
Bitewings - four radiographic images |
80 |
77 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
136 |
123 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
274 |
250 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
116 |
99 |
$960.44 |
| D1120 |
Prophylaxis - child |
41 |
33 |
$640.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$120.00 |