| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
137 |
136 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
68 |
68 |
$2K |
| D1120 |
Prophylaxis - child |
44 |
44 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
113 |
110 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
99 |
85 |
$1K |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$893.33 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$828.86 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$486.57 |
| D0603 |
|
209 |
201 |
$0.00 |