| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
405 |
405 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
371 |
370 |
$9K |
| D0330 |
Panoramic radiographic image |
163 |
162 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
152 |
149 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
234 |
234 |
$6K |
| D1206 |
Topical application of fluoride varnish |
64 |
64 |
$2K |
| D1120 |
Prophylaxis - child |
44 |
44 |
$2K |
| D0274 |
Bitewings - four radiographic images |
143 |
143 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
96 |
94 |
$310.00 |