| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
467 |
467 |
$23K |
| D0274 |
Bitewings - four radiographic images |
516 |
516 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
547 |
547 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
616 |
616 |
$10K |
| D0330 |
Panoramic radiographic image |
198 |
198 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
109 |
$4K |
| D0272 |
Bitewings - two radiographic images |
217 |
217 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
318 |
316 |
$4K |
| D1120 |
Prophylaxis - child |
104 |
104 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
75 |
75 |
$3K |