| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
46 |
46 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
49 |
49 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
30 |
$750.00 |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$680.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$600.00 |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$468.00 |
| D0220 |
Intraoral - periapical first radiographic image |
79 |
78 |
$385.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$343.75 |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
45 |
$261.00 |