| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
296 |
156 |
$2K |
| D1120 |
Prophylaxis - child |
184 |
93 |
$1K |
| D1110 |
Prophylaxis - adult |
110 |
61 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
335 |
180 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
349 |
189 |
$923.16 |
| D0274 |
Bitewings - four radiographic images |
126 |
68 |
$899.62 |
| D0230 |
Intraoral - periapical each additional radiographic image |
354 |
185 |
$858.19 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
42 |
$547.46 |
| D0272 |
Bitewings - two radiographic images |
100 |
55 |
$508.64 |
| D0603 |
|
149 |
74 |
$0.00 |
| D0601 |
|
93 |
49 |
$0.00 |
| D0602 |
|
99 |
55 |
$0.00 |