| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
229 |
229 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
262 |
262 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
307 |
307 |
$4K |
| D1110 |
Prophylaxis - adult |
80 |
80 |
$4K |
| D0274 |
Bitewings - four radiographic images |
91 |
91 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$2K |
| D0272 |
Bitewings - two radiographic images |
49 |
49 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
92 |
91 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
72 |
72 |
$748.15 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$0.00 |
| D0601 |
|
138 |
104 |
$0.00 |
| D0603 |
|
214 |
210 |
$0.00 |