| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
187 |
186 |
$5K |
| D1110 |
Prophylaxis - adult |
71 |
70 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
108 |
104 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
158 |
158 |
$2K |
| D1120 |
Prophylaxis - child |
107 |
107 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
97 |
97 |
$2K |
| D0274 |
Bitewings - four radiographic images |
54 |
53 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
78 |
75 |
$380.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
15 |
$160.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$120.00 |