| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
285 |
285 |
$7K |
| D1120 |
Prophylaxis - child |
161 |
161 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
97 |
95 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
145 |
145 |
$3K |
| D1110 |
Prophylaxis - adult |
38 |
37 |
$2K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
46 |
42 |
$737.42 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$635.54 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$514.03 |