| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
76 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
39 |
38 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
98 |
97 |
$574.93 |
| D0330 |
Panoramic radiographic image |
87 |
87 |
$60.94 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$17.95 |
| D0220 |
Intraoral - periapical first radiographic image |
103 |
102 |
$17.41 |
| D0272 |
Bitewings - two radiographic images |
50 |
50 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
15 |
$0.00 |
| D1330 |
|
16 |
15 |
$0.00 |