| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
58 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
152 |
139 |
$2K |
| D4210 |
|
14 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
30 |
28 |
$1K |
| D0603 |
|
71 |
67 |
$680.00 |
| D0140 |
Limited oral evaluation - problem focused |
19 |
18 |
$624.42 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$545.74 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$529.20 |
| D0274 |
Bitewings - four radiographic images |
25 |
24 |
$496.80 |
| D1120 |
Prophylaxis - child |
14 |
12 |
$410.40 |
| D0220 |
Intraoral - periapical first radiographic image |
35 |
32 |
$332.16 |