| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
206 |
205 |
$12K |
| D1110 |
Prophylaxis - adult |
169 |
167 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
380 |
373 |
$8K |
| D1120 |
Prophylaxis - child |
184 |
181 |
$7K |
| D0274 |
Bitewings - four radiographic images |
183 |
181 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
374 |
365 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
112 |
111 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
179 |
173 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
326 |
245 |
$3K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$395.14 |