| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
526 |
526 |
$26K |
| D0274 |
Bitewings - four radiographic images |
596 |
596 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
591 |
591 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
976 |
966 |
$12K |
| D1206 |
Topical application of fluoride varnish |
685 |
685 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
180 |
180 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
648 |
642 |
$6K |
| D0330 |
Panoramic radiographic image |
116 |
116 |
$5K |
| D1120 |
Prophylaxis - child |
99 |
99 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
71 |
71 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
19 |
19 |
$307.80 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$265.16 |