| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
98 |
98 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
65 |
65 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
139 |
139 |
$3K |
| D0330 |
Panoramic radiographic image |
54 |
54 |
$2K |
| D0274 |
Bitewings - four radiographic images |
91 |
91 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
137 |
132 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
81 |
81 |
$649.44 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$413.53 |