| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
173 |
173 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
199 |
199 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
30 |
30 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
241 |
241 |
$4K |
| D1110 |
Prophylaxis - adult |
65 |
65 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
248 |
248 |
$3K |
| D0272 |
Bitewings - two radiographic images |
123 |
123 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
241 |
236 |
$3K |
| D0274 |
Bitewings - four radiographic images |
50 |
50 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
32 |
$1K |
| D0601 |
|
27 |
27 |
$0.00 |
| D0603 |
|
260 |
260 |
$0.00 |