| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
131 |
130 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
157 |
152 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
191 |
186 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
16 |
15 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
166 |
157 |
$2K |
| D1206 |
Topical application of fluoride varnish |
107 |
106 |
$1K |
| D0272 |
Bitewings - two radiographic images |
41 |
41 |
$865.06 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$187.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
12 |
$176.40 |
| D0603 |
|
31 |
31 |
$0.05 |
| D0601 |
|
201 |
196 |
$0.02 |