| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
32 |
24 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,061 |
212 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
24 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
38 |
38 |
$928.50 |
| D1120 |
Prophylaxis - child |
45 |
42 |
$886.50 |
| D0220 |
Intraoral - periapical first radiographic image |
159 |
151 |
$832.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
12 |
12 |
$720.00 |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$621.00 |
| D0272 |
Bitewings - two radiographic images |
94 |
87 |
$384.00 |