| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
512 |
509 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
459 |
457 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
634 |
623 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
143 |
141 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
718 |
710 |
$3K |
| D1120 |
Prophylaxis - child |
78 |
78 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
107 |
107 |
$1K |
| D0274 |
Bitewings - four radiographic images |
104 |
104 |
$1K |
| D0191 |
|
25 |
20 |
$605.00 |
| D0272 |
Bitewings - two radiographic images |
65 |
65 |
$416.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$280.80 |