| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
604 |
604 |
$22K |
| D0274 |
Bitewings - four radiographic images |
628 |
628 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
707 |
707 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
699 |
690 |
$9K |
| D1206 |
Topical application of fluoride varnish |
449 |
449 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
794 |
608 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
129 |
129 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
42 |
$1K |
| D1120 |
Prophylaxis - child |
38 |
38 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$463.53 |