| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
258 |
258 |
$12K |
| D0274 |
Bitewings - four radiographic images |
315 |
315 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
386 |
386 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
230 |
230 |
$7K |
| D1120 |
Prophylaxis - child |
188 |
188 |
$6K |
| D0330 |
Panoramic radiographic image |
69 |
69 |
$3K |
| D1206 |
Topical application of fluoride varnish |
151 |
151 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
176 |
176 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
93 |
93 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$437.50 |