| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
51 |
$2K |
| D1110 |
Prophylaxis - adult |
31 |
31 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
77 |
77 |
$1K |
| D1120 |
Prophylaxis - child |
41 |
41 |
$1K |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$923.58 |
| D0274 |
Bitewings - four radiographic images |
32 |
32 |
$907.84 |
| D0220 |
Intraoral - periapical first radiographic image |
78 |
78 |
$851.76 |
| D0230 |
Intraoral - periapical each additional radiographic image |
69 |
69 |
$828.40 |
| D0272 |
Bitewings - two radiographic images |
32 |
32 |
$628.80 |
| D0120 |
Periodic oral evaluation - established patient |
26 |
26 |
$567.58 |