| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
588 |
565 |
$16K |
| D1120 |
Prophylaxis - child |
332 |
319 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
665 |
633 |
$9K |
| D0274 |
Bitewings - four radiographic images |
151 |
145 |
$5K |
| D1110 |
Prophylaxis - adult |
85 |
82 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
261 |
248 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
245 |
232 |
$2K |
| D0272 |
Bitewings - two radiographic images |
87 |
84 |
$2K |
| D1206 |
Topical application of fluoride varnish |
51 |
51 |
$756.30 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$459.16 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$59.80 |
| D0602 |
|
625 |
599 |
$0.00 |