| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
176 |
167 |
$5K |
| D1120 |
Prophylaxis - child |
127 |
124 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
319 |
310 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
262 |
257 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
315 |
279 |
$3K |
| D0274 |
Bitewings - four radiographic images |
59 |
57 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
44 |
43 |
$1K |
| D1110 |
Prophylaxis - adult |
16 |
15 |
$754.56 |
| D0603 |
|
89 |
87 |
$0.00 |
| D0602 |
|
156 |
153 |
$0.00 |