| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
231 |
218 |
$6K |
| D1110 |
Prophylaxis - adult |
89 |
87 |
$4K |
| D0274 |
Bitewings - four radiographic images |
110 |
108 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
257 |
244 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
253 |
236 |
$3K |
| D1120 |
Prophylaxis - child |
78 |
76 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
160 |
157 |
$2K |
| D0272 |
Bitewings - two radiographic images |
59 |
57 |
$1K |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$176.40 |
| D0603 |
|
271 |
268 |
$0.00 |