| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
613 |
560 |
$16K |
| D1120 |
Prophylaxis - child |
411 |
377 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
711 |
656 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
648 |
597 |
$7K |
| D1110 |
Prophylaxis - adult |
158 |
142 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
570 |
522 |
$6K |
| D1351 |
Sealant - per tooth |
157 |
26 |
$4K |
| D0272 |
Bitewings - two radiographic images |
192 |
175 |
$4K |
| D0274 |
Bitewings - four radiographic images |
118 |
110 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$2K |
| D0602 |
|
722 |
691 |
$0.00 |
| D0603 |
|
22 |
18 |
$0.00 |