| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
179 |
179 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
217 |
216 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
114 |
$6K |
| D1120 |
Prophylaxis - child |
131 |
130 |
$5K |
| D0274 |
Bitewings - four radiographic images |
99 |
99 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
79 |
78 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
43 |
$443.76 |