| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
674 |
544 |
$32K |
| D0272 |
Bitewings - two radiographic images |
470 |
385 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
493 |
383 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
442 |
361 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
505 |
380 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$914.42 |
| D0120 |
Periodic oral evaluation - established patient |
19 |
19 |
$457.52 |
| D1206 |
Topical application of fluoride varnish |
13 |
12 |
$259.40 |