| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
209 |
206 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
237 |
232 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
12 |
$486.40 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
171 |
169 |
$342.55 |
| D0210 |
Intraoral - complete series of radiographic images |
76 |
75 |
$240.00 |
| D0140 |
Limited oral evaluation - problem focused |
39 |
39 |
$67.74 |
| D0230 |
Intraoral - periapical each additional radiographic image |
35 |
13 |
$0.00 |
| D1999 |
|
237 |
229 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
18 |
17 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$0.00 |