| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,904 |
2,904 |
$145K |
| D0120 |
Periodic oral evaluation - established patient |
2,562 |
2,562 |
$66K |
| D0274 |
Bitewings - four radiographic images |
1,341 |
1,340 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
302 |
302 |
$9K |
| D0330 |
Panoramic radiographic image |
205 |
205 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
202 |
200 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
38 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
83 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$177.80 |