| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
49 |
49 |
$2K |
| D0330 |
Panoramic radiographic image |
32 |
32 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$1K |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$559.80 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$302.50 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
30 |
$258.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$206.25 |