| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
510 |
510 |
$23K |
| D0274 |
Bitewings - four radiographic images |
641 |
641 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
308 |
308 |
$6K |
| D0330 |
Panoramic radiographic image |
49 |
49 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$840.00 |
| D0140 |
Limited oral evaluation - problem focused |
29 |
25 |
$628.35 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$306.10 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$255.99 |