| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
274 |
269 |
$4K |
| D1110 |
Prophylaxis - adult |
172 |
169 |
$3K |
| D0274 |
Bitewings - four radiographic images |
271 |
267 |
$3K |
| D0330 |
Panoramic radiographic image |
66 |
66 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
58 |
58 |
$677.00 |
| D0220 |
Intraoral - periapical first radiographic image |
143 |
141 |
$482.00 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
13 |
$322.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
177 |
72 |
$197.00 |
| D0120 |
Periodic oral evaluation - established patient |
16 |
16 |
$111.00 |