| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
233 |
233 |
$12K |
| D1310 |
|
211 |
211 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
69 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
112 |
112 |
$3K |
| D1206 |
Topical application of fluoride varnish |
95 |
95 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
45 |
45 |
$3K |
| D0603 |
|
176 |
176 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
272 |
98 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
19 |
19 |
$855.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |