| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
639 |
606 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
139 |
139 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
241 |
187 |
$2K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
33 |
32 |
$883.52 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
24 |
$568.35 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$312.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
13 |
$122.20 |