| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,094 |
1,092 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
919 |
919 |
$25K |
| D8660 |
|
84 |
83 |
$19K |
| D1206 |
Topical application of fluoride varnish |
1,010 |
1,007 |
$19K |
| D0272 |
Bitewings - two radiographic images |
375 |
373 |
$7K |
| D0603 |
|
993 |
993 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
519 |
203 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
318 |
313 |
$4K |
| D0330 |
Panoramic radiographic image |
110 |
104 |
$4K |
| D9920 |
|
683 |
667 |
$4K |
| D0240 |
|
138 |
75 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
52 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
24 |
$840.00 |
| D1354 |
|
181 |
54 |
$356.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
13 |
$261.00 |
| D1320 |
|
25 |
25 |
$250.00 |
| D1310 |
|
1,136 |
1,136 |
$90.00 |
| D1330 |
|
1,134 |
1,134 |
$30.00 |
| D0350 |
|
42 |
42 |
$0.00 |