| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
821 |
821 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
716 |
716 |
$14K |
| D0274 |
Bitewings - four radiographic images |
481 |
481 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
861 |
829 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
576 |
574 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
92 |
92 |
$2K |
| D0330 |
Panoramic radiographic image |
51 |
51 |
$1K |
| D0350 |
|
144 |
144 |
$915.20 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$480.00 |
| D0140 |
Limited oral evaluation - problem focused |
36 |
36 |
$412.87 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$156.80 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$120.00 |
| D1330 |
|
61 |
61 |
$0.00 |
| D1310 |
|
61 |
61 |
$0.00 |