| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
170 |
161 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
55 |
$3K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
21 |
21 |
$1K |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$737.89 |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
58 |
$654.69 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$597.35 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$309.04 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$144.32 |