| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
445 |
445 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
362 |
362 |
$10K |
| D0274 |
Bitewings - four radiographic images |
191 |
191 |
$5K |
| D0330 |
Panoramic radiographic image |
53 |
53 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
34 |
34 |
$966.00 |
| D0140 |
Limited oral evaluation - problem focused |
62 |
61 |
$844.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$182.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$146.90 |
| D1999 |
|
95 |
91 |
$0.00 |
| D9996 |
|
32 |
32 |
$0.00 |
| D9995 |
|
13 |
12 |
$0.00 |