| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,753 |
1,748 |
$67K |
| D2752 |
|
66 |
40 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,037 |
1,030 |
$20K |
| D0274 |
Bitewings - four radiographic images |
877 |
877 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
849 |
847 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,521 |
1,517 |
$15K |
| D0330 |
Panoramic radiographic image |
417 |
417 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,250 |
1,247 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
65 |
64 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
141 |
140 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$66.40 |