| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,217 |
2,214 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
1,612 |
1,611 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,639 |
1,639 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,604 |
2,439 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
2,783 |
2,762 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
573 |
572 |
$13K |
| D0272 |
Bitewings - two radiographic images |
592 |
588 |
$6K |
| D0330 |
Panoramic radiographic image |
161 |
160 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
147 |
147 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
113 |
112 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$403.14 |