| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
420 |
406 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
466 |
453 |
$10K |
| D0272 |
Bitewings - two radiographic images |
407 |
391 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
386 |
365 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
182 |
177 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
323 |
295 |
$4K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$2K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$1K |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$469.00 |