| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
442 |
306 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
397 |
258 |
$2K |
| D1120 |
Prophylaxis - child |
284 |
168 |
$680.00 |
| D1110 |
Prophylaxis - adult |
207 |
118 |
$188.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
277 |
154 |
$152.00 |
| D0272 |
Bitewings - two radiographic images |
130 |
75 |
$120.00 |
| D0220 |
Intraoral - periapical first radiographic image |
538 |
297 |
$104.00 |
| D0274 |
Bitewings - four radiographic images |
158 |
89 |
$87.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
575 |
180 |
$63.00 |
| D0210 |
Intraoral - complete series of radiographic images |
129 |
68 |
$58.00 |
| D0140 |
Limited oral evaluation - problem focused |
290 |
156 |
$35.00 |
| D0170 |
|
144 |
80 |
$28.00 |
| D1354 |
|
788 |
86 |
$28.00 |
| D0603 |
|
171 |
92 |
$0.00 |
| D0602 |
|
52 |
28 |
$0.00 |
| D0601 |
|
147 |
80 |
$0.00 |
| D1330 |
|
565 |
317 |
$0.00 |
| D1999 |
|
16 |
15 |
$0.00 |