| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
367 |
367 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
529 |
529 |
$11K |
| D0274 |
Bitewings - four radiographic images |
248 |
248 |
$6K |
| D1206 |
Topical application of fluoride varnish |
289 |
289 |
$5K |
| D1120 |
Prophylaxis - child |
139 |
139 |
$4K |
| D0330 |
Panoramic radiographic image |
64 |
64 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
62 |
62 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
29 |
$361.87 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$259.20 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$227.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
13 |
$129.31 |