| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
149 |
146 |
$7K |
| D1206 |
Topical application of fluoride varnish |
158 |
153 |
$5K |
| D0330 |
Panoramic radiographic image |
110 |
108 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
99 |
99 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
102 |
100 |
$3K |
| D1120 |
Prophylaxis - child |
43 |
43 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
16 |
15 |
$693.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$330.00 |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
85 |
$300.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$143.00 |