| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$1K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
59 |
59 |
$1K |
| D0274 |
Bitewings - four radiographic images |
35 |
35 |
$992.95 |
| D1120 |
Prophylaxis - child |
30 |
30 |
$917.10 |
| D0220 |
Intraoral - periapical first radiographic image |
69 |
69 |
$753.48 |
| D0230 |
Intraoral - periapical each additional radiographic image |
60 |
60 |
$688.88 |
| D0120 |
Periodic oral evaluation - established patient |
24 |
24 |
$523.92 |
| D0140 |
Limited oral evaluation - problem focused |
18 |
18 |
$510.66 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$294.75 |