| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
315 |
257 |
$8K |
| D1999 |
|
424 |
317 |
$4K |
| D0272 |
Bitewings - two radiographic images |
178 |
159 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
146 |
121 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
482 |
144 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
128 |
99 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
175 |
153 |
$951.33 |
| D1208 |
Topical application of fluoride, excluding varnish |
47 |
45 |
$594.00 |
| D0330 |
Panoramic radiographic image |
16 |
14 |
$469.00 |
| D1120 |
Prophylaxis - child |
15 |
13 |
$210.60 |