| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
589 |
516 |
$4K |
| D1206 |
Topical application of fluoride varnish |
518 |
472 |
$2K |
| D1110 |
Prophylaxis - adult |
150 |
134 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
128 |
120 |
$955.00 |
| D1120 |
Prophylaxis - child |
171 |
162 |
$831.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
956 |
427 |
$590.70 |
| D0272 |
Bitewings - two radiographic images |
409 |
366 |
$506.00 |
| D0330 |
Panoramic radiographic image |
17 |
12 |
$60.00 |
| D1999 |
|
36 |
30 |
$60.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
16 |
$22.20 |