| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
52 |
51 |
$2K |
| D9110 |
|
37 |
35 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
62 |
61 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
87 |
84 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
58 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
32 |
$1K |
| D0274 |
Bitewings - four radiographic images |
44 |
44 |
$797.60 |
| D0220 |
Intraoral - periapical first radiographic image |
128 |
117 |
$793.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
29 |
$791.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
165 |
100 |
$655.02 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$252.00 |