| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,241 |
1,240 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,318 |
1,318 |
$26K |
| D0274 |
Bitewings - four radiographic images |
912 |
911 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
951 |
947 |
$8K |
| D0330 |
Panoramic radiographic image |
306 |
306 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
171 |
171 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
138 |
138 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
625 |
617 |
$3K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$388.84 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$164.20 |
| D1999 |
|
43 |
43 |
$0.00 |