| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
75 |
73 |
$885.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
208 |
101 |
$540.97 |
| D1208 |
Topical application of fluoride, excluding varnish |
98 |
90 |
$514.50 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$415.32 |
| D0220 |
Intraoral - periapical first radiographic image |
113 |
102 |
$401.92 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
19 |
14 |
$70.64 |
| D0603 |
|
216 |
192 |
$0.00 |
| D0602 |
|
15 |
15 |
$0.00 |
| D1120 |
Prophylaxis - child |
17 |
14 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
27 |
18 |
$0.00 |