| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
72 |
72 |
$3K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$797.50 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$594.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$420.00 |
| D0120 |
Periodic oral evaluation - established patient |
15 |
15 |
$385.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$385.00 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
15 |
$54.00 |