| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
495 |
495 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
656 |
655 |
$13K |
| D0274 |
Bitewings - four radiographic images |
877 |
876 |
$12K |
| D0330 |
Panoramic radiographic image |
413 |
411 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
517 |
516 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
185 |
184 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
76 |
67 |
$853.36 |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$319.51 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$145.26 |
| D1999 |
|
30 |
29 |
$0.00 |