| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
42 |
42 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
44 |
$3K |
| D1110 |
Prophylaxis - adult |
48 |
47 |
$619.07 |
| D0330 |
Panoramic radiographic image |
45 |
44 |
$121.62 |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$0.00 |
| D1330 |
|
26 |
26 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
49 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
67 |
66 |
$0.00 |