| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
636 |
636 |
$52K |
| D1120 |
Prophylaxis - child |
714 |
713 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
443 |
440 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$4K |
| D0272 |
Bitewings - two radiographic images |
280 |
278 |
$2K |
| D1206 |
Topical application of fluoride varnish |
719 |
718 |
$572.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
373 |
349 |
$206.05 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$0.00 |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$0.00 |