| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
936 |
824 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,021 |
916 |
$23K |
| D0274 |
Bitewings - four radiographic images |
316 |
295 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
261 |
246 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
143 |
123 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
42 |
$2K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$535.04 |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
32 |
$440.30 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$358.56 |
| D1999 |
|
223 |
213 |
$0.00 |
| D1330 |
|
18 |
18 |
$0.00 |