| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
166 |
166 |
$5K |
| D1120 |
Prophylaxis - child |
69 |
69 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
370 |
362 |
$2K |
| D0274 |
Bitewings - four radiographic images |
67 |
67 |
$963.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
61 |
61 |
$671.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
179 |
174 |
$609.00 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$592.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$396.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$384.00 |
| D1330 |
|
12 |
12 |
$0.00 |