| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,707 |
1,707 |
$110K |
| D0120 |
Periodic oral evaluation - established patient |
1,499 |
1,499 |
$48K |
| D0274 |
Bitewings - four radiographic images |
504 |
504 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
909 |
909 |
$14K |
| D1120 |
Prophylaxis - child |
127 |
127 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
184 |
182 |
$2K |
| D1206 |
Topical application of fluoride varnish |
46 |
46 |
$1K |
| D0272 |
Bitewings - two radiographic images |
33 |
33 |
$673.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
77 |
56 |
$448.00 |