| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
179 |
165 |
$5K |
| D1110 |
Prophylaxis - adult |
91 |
88 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
425 |
405 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
113 |
107 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
51 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
75 |
74 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$526.50 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$509.16 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$362.07 |
| D1330 |
|
468 |
445 |
$0.00 |