| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
169 |
166 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
214 |
211 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
43 |
$747.50 |
| D0274 |
Bitewings - four radiographic images |
40 |
39 |
$721.26 |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
54 |
$473.64 |
| D0230 |
Intraoral - periapical each additional radiographic image |
56 |
56 |
$368.11 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$368.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$132.90 |