| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
86 |
83 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
215 |
204 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
68 |
67 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$451.20 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$413.66 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
22 |
15 |
$373.60 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$323.84 |
| D0230 |
Intraoral - periapical each additional radiographic image |
53 |
41 |
$257.78 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$178.50 |
| D1999 |
|
65 |
63 |
$0.00 |