| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
419 |
415 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
229 |
226 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
616 |
549 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
244 |
240 |
$16K |
| D1120 |
Prophylaxis - child |
494 |
493 |
$9K |
| D0330 |
Panoramic radiographic image |
197 |
196 |
$6K |
| D1110 |
Prophylaxis - adult |
295 |
292 |
$2K |
| D1206 |
Topical application of fluoride varnish |
563 |
562 |
$2K |
| D0274 |
Bitewings - four radiographic images |
363 |
360 |
$689.71 |
| D0230 |
Intraoral - periapical each additional radiographic image |
129 |
79 |
$631.14 |
| D0272 |
Bitewings - two radiographic images |
67 |
67 |
$161.34 |