| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
462 |
298 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
200 |
107 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
439 |
267 |
$8K |
| D0274 |
Bitewings - four radiographic images |
582 |
307 |
$8K |
| D0330 |
Panoramic radiographic image |
564 |
249 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
423 |
264 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
209 |
104 |
$2K |
| D1120 |
Prophylaxis - child |
34 |
26 |
$364.04 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
27 |
$151.74 |