| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
87 |
$2K |
| D1110 |
Prophylaxis - adult |
50 |
50 |
$2K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$1K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
68 |
68 |
$961.50 |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$938.51 |
| D0272 |
Bitewings - two radiographic images |
18 |
18 |
$286.92 |
| D0220 |
Intraoral - periapical first radiographic image |
33 |
33 |
$283.88 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
15 |
$101.86 |