| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
140 |
140 |
$6K |
| D1120 |
Prophylaxis - child |
174 |
171 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
82 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
166 |
137 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
130 |
129 |
$1K |
| D0272 |
Bitewings - two radiographic images |
84 |
82 |
$922.00 |
| D0220 |
Intraoral - periapical first radiographic image |
62 |
56 |
$624.00 |
| D0350 |
|
16 |
14 |
$297.60 |