| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
174 |
162 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
207 |
192 |
$8K |
| D4341 |
|
54 |
16 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
157 |
148 |
$5K |
| D0330 |
Panoramic radiographic image |
64 |
61 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
149 |
113 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
92 |
85 |
$2K |
| D0180 |
|
29 |
29 |
$999.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
12 |
$221.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
21 |
20 |
$62.00 |
| D1330 |
|
20 |
20 |
$0.00 |