| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0999 |
Unspecified diagnostic procedure, by report |
310 |
264 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
105 |
88 |
$104.17 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
32 |
$104.17 |
| D1120 |
Prophylaxis - child |
61 |
61 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
17 |
17 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
59 |
39 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
56 |
56 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
61 |
60 |
$0.00 |