| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
892 |
884 |
$51K |
| D0140 |
Limited oral evaluation - problem focused |
865 |
813 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,085 |
1,067 |
$23K |
| D2750 |
|
45 |
27 |
$23K |
| D0274 |
Bitewings - four radiographic images |
645 |
636 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,287 |
1,163 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
632 |
536 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
210 |
210 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
54 |
$3K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$828.00 |