| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
564 |
564 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
479 |
474 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
739 |
739 |
$16K |
| D0274 |
Bitewings - four radiographic images |
369 |
369 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
751 |
730 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
153 |
153 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
360 |
360 |
$6K |
| D0330 |
Panoramic radiographic image |
43 |
43 |
$2K |
| D1120 |
Prophylaxis - child |
51 |
51 |
$2K |