| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
189 |
159 |
$2K |
| D1120 |
Prophylaxis - child |
117 |
96 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
190 |
172 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
224 |
191 |
$992.24 |
| D0145 |
Oral evaluation for a patient under three years of age |
17 |
13 |
$923.52 |
| D0230 |
Intraoral - periapical each additional radiographic image |
215 |
184 |
$843.93 |
| D0274 |
Bitewings - four radiographic images |
60 |
47 |
$726.60 |
| D1110 |
Prophylaxis - adult |
21 |
19 |
$493.92 |
| D0272 |
Bitewings - two radiographic images |
16 |
13 |
$23.38 |
| D0602 |
|
81 |
77 |
$0.00 |
| D0603 |
|
132 |
107 |
$0.00 |