| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
168 |
168 |
$6K |
| D1206 |
Topical application of fluoride varnish |
201 |
201 |
$5K |
| D1120 |
Prophylaxis - child |
123 |
123 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
132 |
132 |
$5K |
| D0330 |
Panoramic radiographic image |
50 |
50 |
$3K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
54 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
18 |
18 |
$999.34 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$575.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
12 |
$528.98 |