| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
732 |
730 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
385 |
384 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
194 |
194 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
77 |
77 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
698 |
688 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
52 |
51 |
$2K |
| D0274 |
Bitewings - four radiographic images |
179 |
178 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
480 |
478 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$504.00 |