| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
390 |
386 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
645 |
627 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
644 |
626 |
$9K |
| D1120 |
Prophylaxis - child |
209 |
202 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
368 |
354 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
306 |
289 |
$3K |
| D0274 |
Bitewings - four radiographic images |
84 |
83 |
$2K |
| D0272 |
Bitewings - two radiographic images |
31 |
27 |
$431.92 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$322.35 |
| D0601 |
|
29 |
29 |
$135.00 |