| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
78 |
78 |
$5K |
| D9430 |
|
129 |
128 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
59 |
59 |
$3K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$860.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$630.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
37 |
37 |
$554.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
71 |
41 |
$287.55 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$280.80 |