| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
115 |
115 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
246 |
246 |
$5K |
| D0330 |
Panoramic radiographic image |
96 |
96 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
206 |
206 |
$3K |
| D0272 |
Bitewings - two radiographic images |
182 |
182 |
$3K |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$988.70 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$153.96 |