| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
92 |
92 |
$4K |
| D0330 |
Panoramic radiographic image |
63 |
63 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
76 |
76 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
44 |
$1K |
| D1120 |
Prophylaxis - child |
15 |
15 |
$693.00 |
| D0120 |
Periodic oral evaluation - established patient |
23 |
23 |
$577.50 |
| D1206 |
Topical application of fluoride varnish |
18 |
18 |
$560.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$544.50 |
| D0220 |
Intraoral - periapical first radiographic image |
65 |
64 |
$226.00 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$182.00 |