| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
497 |
488 |
$3K |
| D1120 |
Prophylaxis - child |
298 |
296 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
127 |
127 |
$2K |
| D1206 |
Topical application of fluoride varnish |
503 |
495 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$464.00 |
| D0220 |
Intraoral - periapical first radiographic image |
202 |
193 |
$274.12 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$260.46 |
| D1110 |
Prophylaxis - adult |
41 |
40 |
$195.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
172 |
152 |
$152.96 |
| D0272 |
Bitewings - two radiographic images |
42 |
41 |
$11.00 |
| D1330 |
|
543 |
522 |
$0.00 |
| D1999 |
|
12 |
12 |
$0.00 |