| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
123 |
118 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
137 |
136 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
538 |
502 |
$5K |
| D1110 |
Prophylaxis - adult |
78 |
77 |
$2K |
| D1206 |
Topical application of fluoride varnish |
86 |
86 |
$1K |
| D0330 |
Panoramic radiographic image |
48 |
45 |
$704.65 |
| D0274 |
Bitewings - four radiographic images |
287 |
274 |
$533.61 |
| D0230 |
Intraoral - periapical each additional radiographic image |
648 |
353 |
$341.42 |
| D1120 |
Prophylaxis - child |
81 |
81 |
$49.65 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$0.00 |