| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
111 |
111 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
159 |
159 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
76 |
76 |
$2K |
| D0274 |
Bitewings - four radiographic images |
134 |
134 |
$2K |
| D1206 |
Topical application of fluoride varnish |
41 |
41 |
$1K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$357.50 |
| D0220 |
Intraoral - periapical first radiographic image |
69 |
67 |
$258.00 |