| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
45 |
45 |
$6K |
| D1120 |
Prophylaxis - child |
64 |
64 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
40 |
40 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
53 |
53 |
$779.10 |
| D0272 |
Bitewings - two radiographic images |
31 |
31 |
$724.78 |
| D0230 |
Intraoral - periapical each additional radiographic image |
41 |
35 |
$483.42 |
| D0220 |
Intraoral - periapical first radiographic image |
36 |
36 |
$439.60 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$423.84 |
| D1206 |
Topical application of fluoride varnish |
21 |
21 |
$308.70 |
| D0603 |
|
186 |
185 |
$0.33 |