| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
24 |
24 |
$3K |
| D1120 |
Prophylaxis - child |
76 |
76 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
94 |
94 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
132 |
132 |
$2K |
| D1110 |
Prophylaxis - adult |
34 |
34 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
124 |
108 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
113 |
111 |
$1K |
| D0274 |
Bitewings - four radiographic images |
38 |
38 |
$1K |
| D0272 |
Bitewings - two radiographic images |
35 |
35 |
$794.92 |
| D0603 |
|
117 |
117 |
$0.00 |
| D0602 |
|
33 |
33 |
$0.00 |