| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
358 |
357 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
637 |
636 |
$16K |
| D1206 |
Topical application of fluoride varnish |
330 |
329 |
$10K |
| D1120 |
Prophylaxis - child |
228 |
228 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
560 |
552 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
738 |
708 |
$4K |
| D0274 |
Bitewings - four radiographic images |
205 |
205 |
$2K |
| D0272 |
Bitewings - two radiographic images |
112 |
112 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
41 |
41 |
$1K |