| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
85 |
37 |
$15K |
| D1120 |
Prophylaxis - child |
282 |
277 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
271 |
260 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
302 |
297 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
227 |
223 |
$6K |
| D0274 |
Bitewings - four radiographic images |
296 |
288 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
455 |
443 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
349 |
331 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
170 |
167 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
62 |
59 |
$858.60 |
| D0330 |
Panoramic radiographic image |
67 |
65 |
$723.20 |
| D9110 |
|
12 |
12 |
$605.00 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$386.80 |