| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
551 |
525 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
773 |
740 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,710 |
1,518 |
$18K |
| D0274 |
Bitewings - four radiographic images |
879 |
818 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
80 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,210 |
1,052 |
$7K |
| D1120 |
Prophylaxis - child |
186 |
180 |
$4K |
| D1206 |
Topical application of fluoride varnish |
177 |
174 |
$2K |
| D0272 |
Bitewings - two radiographic images |
29 |
28 |
$129.66 |
| D0330 |
Panoramic radiographic image |
43 |
42 |
$0.00 |