| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
231 |
227 |
$6K |
| D1120 |
Prophylaxis - child |
124 |
120 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
278 |
134 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
192 |
188 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
202 |
195 |
$2K |
| D0272 |
Bitewings - two radiographic images |
42 |
41 |
$935.20 |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$761.42 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$713.44 |
| D1206 |
Topical application of fluoride varnish |
15 |
14 |
$191.10 |
| D0603 |
|
408 |
398 |
$0.00 |