| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
201 |
201 |
$4K |
| D1120 |
Prophylaxis - child |
159 |
159 |
$3K |
| D1110 |
Prophylaxis - adult |
77 |
75 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
266 |
264 |
$2K |
| D0274 |
Bitewings - four radiographic images |
111 |
109 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
294 |
284 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
61 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
296 |
271 |
$2K |
| D0272 |
Bitewings - two radiographic images |
130 |
130 |
$2K |
| D0602 |
|
121 |
119 |
$0.00 |
| D0603 |
|
60 |
60 |
$0.00 |
| D0601 |
|
42 |
42 |
$0.00 |