| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
155 |
151 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
99 |
92 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
131 |
127 |
$12K |
| D1110 |
Prophylaxis - adult |
241 |
229 |
$774.80 |
| D0330 |
Panoramic radiographic image |
109 |
103 |
$514.08 |
| D0274 |
Bitewings - four radiographic images |
294 |
283 |
$411.24 |
| D0220 |
Intraoral - periapical first radiographic image |
157 |
154 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
16 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$0.00 |