| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
487 |
433 |
$11K |
| D1120 |
Prophylaxis - child |
86 |
81 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
78 |
67 |
$2K |
| D1206 |
Topical application of fluoride varnish |
230 |
208 |
$2K |
| D1110 |
Prophylaxis - adult |
53 |
44 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
20 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
69 |
55 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
79 |
71 |
$593.48 |
| D0230 |
Intraoral - periapical each additional radiographic image |
66 |
40 |
$349.79 |
| D0603 |
|
537 |
513 |
$182.02 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$161.70 |
| D1330 |
|
106 |
100 |
$37.00 |
| D1310 |
|
29 |
29 |
$0.00 |