| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
332 |
329 |
$6K |
| D1120 |
Prophylaxis - child |
175 |
172 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
301 |
298 |
$3K |
| D1110 |
Prophylaxis - adult |
66 |
66 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
268 |
265 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
266 |
260 |
$2K |
| D0272 |
Bitewings - two radiographic images |
116 |
114 |
$2K |
| D0274 |
Bitewings - four radiographic images |
63 |
63 |
$1K |
| D1206 |
Topical application of fluoride varnish |
29 |
29 |
$426.30 |
| D0603 |
|
374 |
373 |
$0.00 |