| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
154 |
153 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
100 |
100 |
$4K |
| D0330 |
Panoramic radiographic image |
65 |
65 |
$2K |
| D1120 |
Prophylaxis - child |
58 |
58 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
142 |
140 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$630.00 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$525.00 |
| D0350 |
|
25 |
14 |
$259.20 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$237.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
53 |
16 |
$214.65 |