| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
117 |
100 |
$2K |
| D1120 |
Prophylaxis - child |
88 |
82 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
89 |
85 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
199 |
177 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
261 |
112 |
$2K |
| D1110 |
Prophylaxis - adult |
41 |
37 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
152 |
125 |
$1K |
| D0330 |
Panoramic radiographic image |
43 |
39 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
14 |
$911.26 |
| D0274 |
Bitewings - four radiographic images |
44 |
40 |
$857.65 |
| D1206 |
Topical application of fluoride varnish |
44 |
43 |
$527.73 |
| D0272 |
Bitewings - two radiographic images |
13 |
12 |
$187.04 |
| D0602 |
|
267 |
250 |
$0.00 |
| D0603 |
|
100 |
86 |
$0.00 |
| D0601 |
|
17 |
17 |
$0.00 |