| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
142 |
137 |
$3K |
| D1120 |
Prophylaxis - child |
70 |
70 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
62 |
62 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
78 |
78 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
137 |
136 |
$1K |
| D0272 |
Bitewings - two radiographic images |
35 |
35 |
$1K |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$779.23 |
| D0230 |
Intraoral - periapical each additional radiographic image |
25 |
25 |
$318.89 |
| D1999 |
|
12 |
12 |
$0.00 |