| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,055 |
1,051 |
$57K |
| D1120 |
Prophylaxis - child |
906 |
904 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
273 |
273 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,725 |
1,327 |
$11K |
| D1110 |
Prophylaxis - adult |
52 |
52 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
366 |
366 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
81 |
81 |
$4K |
| D0272 |
Bitewings - two radiographic images |
220 |
220 |
$3K |
| D0274 |
Bitewings - four radiographic images |
120 |
120 |
$3K |
| D9430 |
|
37 |
36 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
36 |
36 |
$432.00 |