| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
100 |
100 |
$3K |
| D0274 |
Bitewings - four radiographic images |
111 |
111 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
119 |
117 |
$2K |
| D1110 |
Prophylaxis - adult |
38 |
37 |
$1K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
67 |
67 |
$975.00 |
| D1120 |
Prophylaxis - child |
40 |
40 |
$780.00 |
| D0220 |
Intraoral - periapical first radiographic image |
130 |
127 |
$650.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
87 |
30 |
$425.00 |
| D0140 |
Limited oral evaluation - problem focused |
18 |
17 |
$361.28 |