| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
70 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
159 |
137 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
147 |
75 |
$2K |
| D1110 |
Prophylaxis - adult |
29 |
29 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
49 |
40 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$701.87 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$297.96 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$241.80 |