| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
518 |
518 |
$15K |
| D1120 |
Prophylaxis - child |
390 |
390 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,095 |
372 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
73 |
73 |
$10K |
| D1206 |
Topical application of fluoride varnish |
337 |
337 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
396 |
396 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
129 |
129 |
$2K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$865.25 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$847.68 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$658.56 |
| D9986 |
|
43 |
43 |
$0.00 |
| D0603 |
|
146 |
144 |
$0.00 |
| D0602 |
|
535 |
533 |
$0.00 |