| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
788 |
788 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
760 |
746 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
359 |
356 |
$9K |
| D1206 |
Topical application of fluoride varnish |
143 |
143 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
744 |
737 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
628 |
625 |
$4K |
| D0274 |
Bitewings - four radiographic images |
234 |
234 |
$3K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$585.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$120.00 |