| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
241 |
233 |
$7K |
| D1120 |
Prophylaxis - child |
185 |
182 |
$6K |
| D1206 |
Topical application of fluoride varnish |
453 |
437 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
299 |
281 |
$3K |
| D1110 |
Prophylaxis - adult |
47 |
44 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
245 |
227 |
$2K |
| D0272 |
Bitewings - two radiographic images |
81 |
81 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$423.84 |
| D0274 |
Bitewings - four radiographic images |
13 |
12 |
$415.32 |
| D0350 |
|
13 |
12 |
$220.56 |
| D0603 |
|
721 |
701 |
$0.00 |
| D1330 |
|
142 |
139 |
$0.00 |