| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
679 |
679 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
676 |
676 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
500 |
499 |
$12K |
| D1206 |
Topical application of fluoride varnish |
95 |
95 |
$3K |
| D0603 |
|
273 |
273 |
$3K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$2K |
| D0272 |
Bitewings - two radiographic images |
131 |
131 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
229 |
229 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
169 |
169 |
$603.00 |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$444.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$350.00 |