| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
462 |
459 |
$30K |
| D1206 |
Topical application of fluoride varnish |
472 |
472 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
211 |
210 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
312 |
310 |
$10K |
| D0274 |
Bitewings - four radiographic images |
286 |
286 |
$7K |
| D0330 |
Panoramic radiographic image |
83 |
83 |
$4K |
| D1120 |
Prophylaxis - child |
86 |
86 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
38 |
38 |
$874.00 |
| D0220 |
Intraoral - periapical first radiographic image |
60 |
60 |
$663.89 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$229.74 |