| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
166 |
161 |
$4K |
| D1120 |
Prophylaxis - child |
93 |
90 |
$3K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
49 |
48 |
$690.90 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$565.12 |
| D0272 |
Bitewings - two radiographic images |
28 |
27 |
$561.12 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$484.54 |
| D0220 |
Intraoral - periapical first radiographic image |
57 |
54 |
$484.14 |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
30 |
$276.24 |
| D0603 |
|
490 |
483 |
$0.00 |
| D1999 |
|
207 |
173 |
$0.00 |