| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
152 |
152 |
$4K |
| D1120 |
Prophylaxis - child |
99 |
99 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
99 |
99 |
$3K |
| D0274 |
Bitewings - four radiographic images |
74 |
74 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
131 |
129 |
$846.08 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$671.99 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$652.00 |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$535.36 |
| D0230 |
Intraoral - periapical each additional radiographic image |
99 |
98 |
$456.96 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$308.00 |
| D9310 |
|
12 |
12 |
$205.20 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$121.99 |