| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
199 |
198 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
221 |
220 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
214 |
214 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
48 |
$2K |
| D2954 |
|
21 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
65 |
64 |
$1K |
| D1120 |
Prophylaxis - child |
32 |
32 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
239 |
214 |
$998.12 |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$748.00 |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$390.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
81 |
72 |
$252.00 |