| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
163 |
163 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
145 |
145 |
$4K |
| D0274 |
Bitewings - four radiographic images |
138 |
138 |
$3K |
| D0330 |
Panoramic radiographic image |
92 |
92 |
$3K |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
38 |
38 |
$548.55 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$516.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
29 |
29 |
$290.00 |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
55 |
$208.95 |