| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
591 |
527 |
$20K |
| D0274 |
Bitewings - four radiographic images |
387 |
351 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
372 |
339 |
$6K |
| D0330 |
Panoramic radiographic image |
169 |
145 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
201 |
171 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
97 |
81 |
$2K |
| D1120 |
Prophylaxis - child |
44 |
44 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
105 |
102 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
73 |
50 |
$416.88 |