| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
29 |
29 |
$4K |
| D1120 |
Prophylaxis - child |
66 |
65 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
148 |
143 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
59 |
54 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
114 |
103 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
129 |
97 |
$1K |
| D1110 |
Prophylaxis - adult |
28 |
24 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$847.68 |
| D0274 |
Bitewings - four radiographic images |
48 |
44 |
$754.81 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$459.16 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$257.18 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$0.00 |
| D0601 |
|
156 |
154 |
$0.00 |