| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
43 |
43 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
191 |
179 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
70 |
68 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
140 |
129 |
$1K |
| D1110 |
Prophylaxis - adult |
42 |
39 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
145 |
123 |
$1K |
| D1120 |
Prophylaxis - child |
39 |
38 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
37 |
$1K |
| D0274 |
Bitewings - four radiographic images |
15 |
14 |
$415.32 |
| D0603 |
|
44 |
39 |
$0.00 |
| D0601 |
|
58 |
56 |
$0.00 |