| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
135 |
134 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
294 |
293 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
198 |
198 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
92 |
91 |
$5K |
| D1120 |
Prophylaxis - child |
113 |
113 |
$4K |
| D0274 |
Bitewings - four radiographic images |
116 |
115 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
221 |
220 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
56 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
197 |
172 |
$2K |