| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
306 |
305 |
$8K |
| D1110 |
Prophylaxis - adult |
152 |
152 |
$5K |
| D0330 |
Panoramic radiographic image |
91 |
91 |
$4K |
| D1120 |
Prophylaxis - child |
207 |
201 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
210 |
202 |
$4K |
| D1206 |
Topical application of fluoride varnish |
230 |
223 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
68 |
49 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
47 |
47 |
$1K |
| D0274 |
Bitewings - four radiographic images |
101 |
97 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
107 |
106 |
$556.50 |
| D0272 |
Bitewings - two radiographic images |
36 |
36 |
$357.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
49 |
49 |
$252.00 |