| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
175 |
174 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
142 |
142 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
109 |
108 |
$3K |
| D1206 |
Topical application of fluoride varnish |
79 |
79 |
$2K |
| D1120 |
Prophylaxis - child |
40 |
40 |
$2K |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$704.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$594.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$330.00 |
| D0220 |
Intraoral - periapical first radiographic image |
69 |
67 |
$270.00 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$208.00 |