| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
140 |
137 |
$17K |
| D1120 |
Prophylaxis - child |
173 |
154 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
43 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
130 |
128 |
$992.24 |
| D1208 |
Topical application of fluoride, excluding varnish |
189 |
168 |
$984.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
79 |
70 |
$702.11 |
| D0272 |
Bitewings - two radiographic images |
66 |
65 |
$654.64 |
| D0120 |
Periodic oral evaluation - established patient |
122 |
104 |
$28.85 |
| D0603 |
|
506 |
469 |
$0.00 |