| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
692 |
683 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,085 |
1,067 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
348 |
343 |
$5K |
| D1120 |
Prophylaxis - child |
150 |
148 |
$3K |
| D0274 |
Bitewings - four radiographic images |
164 |
161 |
$3K |
| D0330 |
Panoramic radiographic image |
17 |
16 |
$490.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$224.00 |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
15 |
$154.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
12 |
$110.00 |