| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
226 |
98 |
$368.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
244 |
102 |
$303.00 |
| D1110 |
Prophylaxis - adult |
88 |
42 |
$300.00 |
| D0274 |
Bitewings - four radiographic images |
46 |
19 |
$155.00 |
| D1120 |
Prophylaxis - child |
149 |
55 |
$136.00 |
| D0272 |
Bitewings - two radiographic images |
53 |
18 |
$44.00 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
14 |
$28.00 |
| D1206 |
Topical application of fluoride varnish |
29 |
13 |
$0.00 |
| D0330 |
Panoramic radiographic image |
22 |
12 |
$0.00 |