| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
116 |
116 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$681.81 |
| D1110 |
Prophylaxis - adult |
72 |
72 |
$56.10 |
| D0272 |
Bitewings - two radiographic images |
161 |
161 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
151 |
151 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
82 |
82 |
$0.00 |
| D1330 |
|
81 |
81 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
163 |
163 |
$0.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$0.00 |