| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
61 |
60 |
$3K |
| D0330 |
Panoramic radiographic image |
54 |
54 |
$2K |
| D1110 |
Prophylaxis - adult |
88 |
87 |
$2K |
| D2140 |
|
34 |
18 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
37 |
37 |
$466.72 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$309.35 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$285.75 |
| D1330 |
|
99 |
98 |
$202.80 |
| D0140 |
Limited oral evaluation - problem focused |
33 |
33 |
$69.84 |
| D0120 |
Periodic oral evaluation - established patient |
30 |
29 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
49 |
48 |
$0.00 |