| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
215 |
213 |
$11K |
| D0274 |
Bitewings - four radiographic images |
192 |
191 |
$6K |
| D0330 |
Panoramic radiographic image |
96 |
95 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
195 |
195 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
85 |
83 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
83 |
82 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
130 |
122 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$1K |
| D1120 |
Prophylaxis - child |
20 |
20 |
$1K |