| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
400 |
399 |
$10K |
| D1120 |
Prophylaxis - child |
181 |
181 |
$8K |
| D1110 |
Prophylaxis - adult |
97 |
97 |
$4K |
| D1206 |
Topical application of fluoride varnish |
64 |
64 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
68 |
68 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
38 |
$950.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$528.00 |
| D0274 |
Bitewings - four radiographic images |
38 |
38 |
$456.00 |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
49 |
$209.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$76.00 |