| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
276 |
276 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
594 |
594 |
$12K |
| D1206 |
Topical application of fluoride varnish |
559 |
558 |
$8K |
| D1120 |
Prophylaxis - child |
214 |
214 |
$6K |
| D0274 |
Bitewings - four radiographic images |
157 |
157 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
93 |
93 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
182 |
177 |
$3K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
181 |
73 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
74 |
74 |
$1K |