| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$4K |
| D1120 |
Prophylaxis - child |
92 |
92 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
354 |
341 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
259 |
190 |
$2K |
| D0272 |
Bitewings - two radiographic images |
141 |
141 |
$795.00 |
| D1206 |
Topical application of fluoride varnish |
49 |
49 |
$718.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$423.00 |
| D0120 |
Periodic oral evaluation - established patient |
27 |
27 |
$302.00 |