| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$2K |
| D1120 |
Prophylaxis - child |
62 |
62 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
96 |
96 |
$2K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$1K |
| D1110 |
Prophylaxis - adult |
32 |
32 |
$1K |
| D0274 |
Bitewings - four radiographic images |
50 |
50 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
105 |
105 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
95 |
95 |
$872.00 |
| D0272 |
Bitewings - two radiographic images |
43 |
43 |
$844.95 |
| D0120 |
Periodic oral evaluation - established patient |
37 |
37 |
$807.71 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$453.92 |