| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
662 |
656 |
$17K |
| D0330 |
Panoramic radiographic image |
128 |
128 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
501 |
494 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
128 |
128 |
$2K |
| D0274 |
Bitewings - four radiographic images |
155 |
155 |
$504.20 |
| D0140 |
Limited oral evaluation - problem focused |
48 |
45 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
13 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
131 |
114 |
$0.00 |