| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
78 |
75 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
74 |
$2K |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$1K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$820.00 |
| D0140 |
Limited oral evaluation - problem focused |
36 |
36 |
$806.88 |
| D0230 |
Intraoral - periapical each additional radiographic image |
86 |
44 |
$430.00 |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
83 |
$397.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$225.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$130.00 |