| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
970 |
970 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,271 |
1,271 |
$28K |
| D0274 |
Bitewings - four radiographic images |
753 |
753 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,172 |
1,172 |
$19K |
| D0330 |
Panoramic radiographic image |
174 |
174 |
$8K |
| D0272 |
Bitewings - two radiographic images |
329 |
329 |
$6K |
| D1120 |
Prophylaxis - child |
149 |
149 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$570.10 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$431.40 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$390.00 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$307.15 |