| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
112 |
112 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
140 |
$5K |
| D0274 |
Bitewings - four radiographic images |
130 |
130 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
223 |
222 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
218 |
195 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
107 |
107 |
$2K |
| D1120 |
Prophylaxis - child |
58 |
58 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
56 |
56 |
$1K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$820.96 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
26 |
$765.99 |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$569.85 |