| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
248 |
243 |
$7K |
| D1120 |
Prophylaxis - child |
137 |
136 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
221 |
217 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
144 |
142 |
$2K |
| D1110 |
Prophylaxis - adult |
31 |
30 |
$1K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
119 |
117 |
$1K |
| D0272 |
Bitewings - two radiographic images |
28 |
27 |
$631.26 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$423.84 |
| D0601 |
|
151 |
149 |
$0.00 |
| D0603 |
|
36 |
36 |
$0.00 |