| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
278 |
278 |
$8K |
| D1110 |
Prophylaxis - adult |
75 |
75 |
$3K |
| D1120 |
Prophylaxis - child |
104 |
104 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
429 |
412 |
$2K |
| D0330 |
Panoramic radiographic image |
39 |
39 |
$1K |
| D0274 |
Bitewings - four radiographic images |
92 |
92 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
100 |
100 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
214 |
212 |
$969.00 |
| D0140 |
Limited oral evaluation - problem focused |
44 |
39 |
$688.00 |