| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
397 |
397 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
471 |
470 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,208 |
1,179 |
$5K |
| D0274 |
Bitewings - four radiographic images |
288 |
288 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
818 |
807 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
39 |
$2K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$975.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$560.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$300.00 |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$290.00 |