| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,094 |
1,094 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,552 |
1,552 |
$44K |
| D1120 |
Prophylaxis - child |
413 |
413 |
$17K |
| D0330 |
Panoramic radiographic image |
238 |
238 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
624 |
624 |
$9K |
| D0274 |
Bitewings - four radiographic images |
145 |
145 |
$4K |
| D0272 |
Bitewings - two radiographic images |
157 |
157 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
89 |
88 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$204.10 |