| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
483 |
483 |
$21K |
| D1110 |
Prophylaxis - adult |
447 |
446 |
$11K |
| D0330 |
Panoramic radiographic image |
151 |
151 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
156 |
156 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
572 |
572 |
$3K |
| D9999 |
Unspecified adjunctive procedure, by report |
15 |
15 |
$1K |
| D1120 |
Prophylaxis - child |
100 |
100 |
$1K |
| D0272 |
Bitewings - two radiographic images |
309 |
309 |
$381.03 |
| D1330 |
|
578 |
578 |
$377.00 |
| D0220 |
Intraoral - periapical first radiographic image |
229 |
227 |
$341.36 |
| D0230 |
Intraoral - periapical each additional radiographic image |
168 |
158 |
$250.18 |
| D0601 |
|
414 |
413 |
$36.00 |