| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
653 |
565 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
436 |
433 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
979 |
892 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
30 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
853 |
548 |
$3K |
| D1120 |
Prophylaxis - child |
403 |
399 |
$1K |
| D0274 |
Bitewings - four radiographic images |
226 |
224 |
$620.22 |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$49.67 |
| D1206 |
Topical application of fluoride varnish |
410 |
406 |
$0.00 |
| D0602 |
|
12 |
12 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
62 |
60 |
$0.00 |