| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
271 |
263 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
220 |
217 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
88 |
86 |
$2K |
| D0330 |
Panoramic radiographic image |
34 |
32 |
$1K |
| D1320 |
|
42 |
42 |
$631.80 |
| D0140 |
Limited oral evaluation - problem focused |
29 |
25 |
$583.75 |
| D1208 |
Topical application of fluoride, excluding varnish |
36 |
35 |
$567.00 |
| D0220 |
Intraoral - periapical first radiographic image |
60 |
59 |
$280.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
43 |
13 |
$273.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$252.00 |