| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,038 |
1,037 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,108 |
1,108 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
964 |
964 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
546 |
543 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
215 |
215 |
$7K |
| D0330 |
Panoramic radiographic image |
354 |
351 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,073 |
1,072 |
$3K |
| D1120 |
Prophylaxis - child |
81 |
81 |
$880.26 |
| D0140 |
Limited oral evaluation - problem focused |
156 |
156 |
$624.04 |
| D1208 |
Topical application of fluoride, excluding varnish |
134 |
134 |
$440.93 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
26 |
$103.82 |