| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
331 |
323 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
579 |
561 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
539 |
515 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
508 |
482 |
$5K |
| D1120 |
Prophylaxis - child |
103 |
98 |
$3K |
| D0274 |
Bitewings - four radiographic images |
72 |
72 |
$2K |
| D1110 |
Prophylaxis - adult |
31 |
31 |
$2K |
| D0272 |
Bitewings - two radiographic images |
83 |
79 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$953.64 |
| D0603 |
|
703 |
682 |
$0.00 |