| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
416 |
403 |
$11K |
| D1120 |
Prophylaxis - child |
91 |
88 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
91 |
88 |
$2K |
| D9110 |
|
33 |
27 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
26 |
$568.35 |
| D0330 |
Panoramic radiographic image |
27 |
26 |
$384.20 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$140.80 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
29 |
$78.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
25 |
25 |
$58.90 |