| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
905 |
904 |
$34K |
| D0274 |
Bitewings - four radiographic images |
664 |
664 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
629 |
627 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
991 |
990 |
$7K |
| D0330 |
Panoramic radiographic image |
60 |
60 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
59 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
279 |
278 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$128.00 |