| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,547 |
1,547 |
$36K |
| D1110 |
Prophylaxis - adult |
482 |
482 |
$17K |
| D1999 |
|
1,295 |
1,217 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
460 |
449 |
$10K |
| D1120 |
Prophylaxis - child |
274 |
274 |
$7K |
| D0272 |
Bitewings - two radiographic images |
182 |
182 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
84 |
$2K |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$475.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$180.00 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$138.00 |