| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
255 |
254 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
759 |
690 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
260 |
259 |
$6K |
| D0330 |
Panoramic radiographic image |
42 |
41 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
43 |
$2K |
| D0274 |
Bitewings - four radiographic images |
25 |
24 |
$895.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
24 |
$744.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
12 |
$203.00 |