| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
87 |
87 |
$8K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$26.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
59 |
59 |
$0.00 |
| D1120 |
Prophylaxis - child |
86 |
86 |
$0.00 |
| D0350 |
|
15 |
15 |
$0.00 |
| D1330 |
|
129 |
128 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
114 |
114 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
87 |
47 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
75 |
75 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$0.00 |