| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
44 |
44 |
$2K |
| D0274 |
Bitewings - four radiographic images |
65 |
65 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
112 |
107 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
61 |
61 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
95 |
84 |
$931.37 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$905.24 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$300.80 |