| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
131 |
128 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
26 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
234 |
230 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
95 |
94 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
74 |
71 |
$2K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
96 |
94 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
89 |
78 |
$894.33 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$847.68 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$415.32 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$257.18 |
| D0603 |
|
346 |
300 |
$0.00 |