| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
826 |
700 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
802 |
659 |
$11K |
| D0274 |
Bitewings - four radiographic images |
397 |
333 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
147 |
120 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
31 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
49 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
104 |
87 |
$912.08 |
| D0330 |
Panoramic radiographic image |
14 |
13 |
$797.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
99 |
81 |
$492.58 |
| D1120 |
Prophylaxis - child |
36 |
29 |
$345.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
30 |
$318.60 |
| D1999 |
|
233 |
174 |
$0.00 |