| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
299 |
297 |
$10K |
| D0274 |
Bitewings - four radiographic images |
173 |
172 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
335 |
333 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
284 |
220 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
124 |
124 |
$2K |
| D1120 |
Prophylaxis - child |
54 |
53 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
54 |
$2K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$1K |
| D1206 |
Topical application of fluoride varnish |
55 |
54 |
$986.21 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$482.45 |