| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
222 |
222 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
291 |
291 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
135 |
$5K |
| D0274 |
Bitewings - four radiographic images |
84 |
84 |
$2K |
| D1206 |
Topical application of fluoride varnish |
127 |
127 |
$2K |
| D1120 |
Prophylaxis - child |
51 |
51 |
$2K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$751.35 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$445.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$227.28 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$194.40 |