| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
28 |
26 |
$839.40 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$447.54 |
| D0274 |
Bitewings - four radiographic images |
19 |
18 |
$361.58 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$315.50 |
| D0120 |
Periodic oral evaluation - established patient |
15 |
13 |
$244.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
13 |
$204.00 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
28 |
$170.18 |
| D0230 |
Intraoral - periapical each additional radiographic image |
37 |
21 |
$114.18 |