| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
190 |
183 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
237 |
230 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
161 |
152 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
90 |
90 |
$1K |
| D0272 |
Bitewings - two radiographic images |
76 |
75 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
105 |
88 |
$901.24 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$363.60 |
| D1206 |
Topical application of fluoride varnish |
16 |
15 |
$185.51 |