| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
373 |
345 |
$8K |
| D0330 |
Panoramic radiographic image |
173 |
154 |
$4K |
| D0272 |
Bitewings - two radiographic images |
278 |
249 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
692 |
137 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
206 |
196 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
122 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
107 |
103 |
$602.09 |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
25 |
$324.00 |