| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,115 |
1,016 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,513 |
1,358 |
$31K |
| D0274 |
Bitewings - four radiographic images |
413 |
372 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
554 |
480 |
$9K |
| D0330 |
Panoramic radiographic image |
68 |
64 |
$2K |
| D1120 |
Prophylaxis - child |
92 |
79 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
47 |
42 |
$571.00 |
| D0220 |
Intraoral - periapical first radiographic image |
33 |
31 |
$178.90 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
13 |
$0.00 |