| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
259 |
254 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
171 |
167 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
104 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
85 |
80 |
$2K |
| D0330 |
Panoramic radiographic image |
27 |
26 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$240.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
12 |
$180.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$55.00 |