| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
383 |
383 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
467 |
466 |
$11K |
| D0274 |
Bitewings - four radiographic images |
184 |
182 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
251 |
249 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
50 |
$2K |
| D1120 |
Prophylaxis - child |
46 |
45 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
76 |
70 |
$961.50 |
| D0330 |
Panoramic radiographic image |
14 |
12 |
$619.52 |
| D0272 |
Bitewings - two radiographic images |
16 |
15 |
$246.26 |