| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
160 |
83 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
332 |
172 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
153 |
81 |
$966.18 |
| D0274 |
Bitewings - four radiographic images |
144 |
77 |
$927.22 |
| D0145 |
Oral evaluation for a patient under three years of age |
23 |
12 |
$781.44 |
| D0220 |
Intraoral - periapical first radiographic image |
295 |
154 |
$694.23 |
| D0230 |
Intraoral - periapical each additional radiographic image |
303 |
152 |
$663.19 |
| D0330 |
Panoramic radiographic image |
23 |
12 |
$294.87 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
13 |
$247.24 |
| D0602 |
|
314 |
164 |
$0.00 |