| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
406 |
400 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
296 |
291 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
313 |
282 |
$2K |
| D1206 |
Topical application of fluoride varnish |
313 |
312 |
$2K |
| D0330 |
Panoramic radiographic image |
50 |
50 |
$1K |
| D0274 |
Bitewings - four radiographic images |
130 |
130 |
$817.34 |
| D0220 |
Intraoral - periapical first radiographic image |
287 |
269 |
$804.30 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$634.79 |
| D0230 |
Intraoral - periapical each additional radiographic image |
249 |
191 |
$570.01 |
| D9110 |
|
38 |
37 |
$0.00 |