| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
241 |
224 |
$9K |
| D1206 |
Topical application of fluoride varnish |
234 |
218 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
150 |
133 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
100 |
95 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
93 |
80 |
$1K |
| D0274 |
Bitewings - four radiographic images |
62 |
55 |
$920.10 |
| D0220 |
Intraoral - periapical first radiographic image |
151 |
142 |
$830.80 |
| D0272 |
Bitewings - two radiographic images |
66 |
63 |
$601.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
75 |
71 |
$418.00 |
| D1999 |
|
210 |
182 |
$0.00 |