| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
45 |
45 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
64 |
64 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
389 |
114 |
$1K |
| D0274 |
Bitewings - four radiographic images |
85 |
84 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
28 |
28 |
$742.25 |
| D0220 |
Intraoral - periapical first radiographic image |
114 |
113 |
$608.53 |
| D1208 |
Topical application of fluoride, excluding varnish |
19 |
19 |
$435.91 |
| D0999 |
Unspecified diagnostic procedure, by report |
22 |
22 |
$0.00 |