| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
44 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
83 |
$1K |
| D1110 |
Prophylaxis - adult |
31 |
30 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
107 |
73 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
43 |
36 |
$933.56 |
| D0274 |
Bitewings - four radiographic images |
35 |
34 |
$905.85 |
| D0330 |
Panoramic radiographic image |
18 |
16 |
$557.55 |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$484.12 |
| D1120 |
Prophylaxis - child |
18 |
17 |
$455.36 |
| D1206 |
Topical application of fluoride varnish |
25 |
23 |
$335.60 |
| D0272 |
Bitewings - two radiographic images |
17 |
16 |
$251.55 |