| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
60 |
60 |
$7K |
| D0274 |
Bitewings - four radiographic images |
104 |
98 |
$2K |
| D1110 |
Prophylaxis - adult |
73 |
68 |
$2K |
| D9110 |
|
76 |
75 |
$2K |
| D0330 |
Panoramic radiographic image |
59 |
58 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
82 |
77 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
130 |
129 |
$868.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$447.84 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$180.00 |