| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
244 |
133 |
$2K |
| D1120 |
Prophylaxis - child |
194 |
108 |
$2K |
| D1110 |
Prophylaxis - adult |
126 |
68 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
55 |
32 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
333 |
182 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
332 |
196 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
419 |
198 |
$989.43 |
| D0274 |
Bitewings - four radiographic images |
106 |
56 |
$906.50 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
35 |
$618.10 |
| D0272 |
Bitewings - two radiographic images |
78 |
40 |
$397.46 |
| D1206 |
Topical application of fluoride varnish |
35 |
19 |
$102.90 |
| D0603 |
|
67 |
44 |
$0.00 |
| D0602 |
|
381 |
211 |
$0.00 |
| D0601 |
|
29 |
14 |
$0.00 |