| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
751 |
741 |
$33K |
| D1120 |
Prophylaxis - child |
472 |
466 |
$15K |
| D0272 |
Bitewings - two radiographic images |
758 |
752 |
$9K |
| D1110 |
Prophylaxis - adult |
100 |
99 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,760 |
843 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
633 |
630 |
$7K |
| D1206 |
Topical application of fluoride varnish |
219 |
219 |
$2K |
| D0330 |
Panoramic radiographic image |
56 |
54 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$384.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$151.20 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
14 |
$140.00 |