| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
271 |
271 |
$8K |
| D1206 |
Topical application of fluoride varnish |
378 |
378 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
253 |
253 |
$5K |
| D0272 |
Bitewings - two radiographic images |
70 |
70 |
$1K |
| D1110 |
Prophylaxis - adult |
31 |
31 |
$1K |
| D0274 |
Bitewings - four radiographic images |
33 |
33 |
$924.00 |
| D0220 |
Intraoral - periapical first radiographic image |
71 |
71 |
$568.00 |
| D0120 |
Periodic oral evaluation - established patient |
15 |
15 |
$450.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
49 |
49 |
$392.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$260.00 |
| D1330 |
|
371 |
370 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
35 |
35 |
$0.00 |