| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
24 |
24 |
$3K |
| D1120 |
Prophylaxis - child |
63 |
62 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
151 |
66 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
97 |
97 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
92 |
92 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$988.64 |
| D0120 |
Periodic oral evaluation - established patient |
23 |
23 |
$660.70 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$303.92 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$220.50 |
| D0603 |
|
97 |
97 |
$0.00 |
| D0601 |
|
69 |
66 |
$0.00 |
| D0602 |
|
16 |
16 |
$0.00 |