| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
595 |
594 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
358 |
357 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
654 |
651 |
$7K |
| D0274 |
Bitewings - four radiographic images |
313 |
313 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
451 |
450 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
104 |
104 |
$2K |
| D0330 |
Panoramic radiographic image |
37 |
36 |
$837.20 |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$670.85 |
| D0350 |
|
28 |
28 |
$311.14 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$167.55 |