| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
109 |
108 |
$2K |
| D1999 |
|
226 |
218 |
$2K |
| D0272 |
Bitewings - two radiographic images |
74 |
72 |
$905.27 |
| D0120 |
Periodic oral evaluation - established patient |
70 |
69 |
$775.20 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
30 |
$463.79 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$334.23 |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
40 |
$214.77 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
15 |
$186.36 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
17 |
$104.16 |