| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
138 |
137 |
$5K |
| D1110 |
Prophylaxis - adult |
168 |
165 |
$5K |
| D0274 |
Bitewings - four radiographic images |
231 |
229 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
116 |
115 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
176 |
174 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
182 |
176 |
$805.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
144 |
129 |
$615.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
18 |
$255.00 |