| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
319 |
317 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
504 |
501 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
505 |
434 |
$4K |
| D1120 |
Prophylaxis - child |
84 |
83 |
$3K |
| D1206 |
Topical application of fluoride varnish |
199 |
199 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
110 |
108 |
$2K |
| D1110 |
Prophylaxis - adult |
26 |
25 |
$1K |
| D0274 |
Bitewings - four radiographic images |
38 |
38 |
$899.86 |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$818.30 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$388.52 |
| D0603 |
|
618 |
614 |
$0.00 |