| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
156 |
155 |
$4K |
| D1120 |
Prophylaxis - child |
91 |
87 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
176 |
172 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
170 |
168 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
144 |
142 |
$2K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$2K |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$631.26 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$519.15 |
| D1330 |
|
13 |
13 |
$134.75 |
| D0602 |
|
140 |
138 |
$0.00 |
| D0603 |
|
15 |
14 |
$0.00 |