| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
167 |
147 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
172 |
148 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
216 |
188 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
247 |
73 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
13 |
$2K |
| D0240 |
|
220 |
92 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
129 |
104 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
47 |
41 |
$1K |
| D0330 |
Panoramic radiographic image |
17 |
15 |
$696.61 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
24 |
$413.16 |
| D0272 |
Bitewings - two radiographic images |
17 |
15 |
$350.70 |
| D0603 |
|
360 |
328 |
$0.00 |