| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
351 |
348 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
549 |
540 |
$14K |
| D0330 |
Panoramic radiographic image |
79 |
77 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
220 |
220 |
$5K |
| D1120 |
Prophylaxis - child |
141 |
141 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
109 |
102 |
$4K |
| D0274 |
Bitewings - four radiographic images |
57 |
55 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$810.85 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
24 |
$115.00 |