| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
228 |
228 |
$7K |
| D1206 |
Topical application of fluoride varnish |
386 |
386 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
239 |
239 |
$5K |
| D0274 |
Bitewings - four radiographic images |
77 |
77 |
$2K |
| D1110 |
Prophylaxis - adult |
54 |
54 |
$2K |
| D0272 |
Bitewings - two radiographic images |
67 |
67 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
78 |
78 |
$646.89 |
| D0230 |
Intraoral - periapical each additional radiographic image |
46 |
46 |
$386.72 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$247.20 |
| D1330 |
|
4,082 |
4,061 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
114 |
114 |
$0.00 |
| D1320 |
|
17 |
17 |
$0.00 |