| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
376 |
376 |
$11K |
| D1110 |
Prophylaxis - adult |
186 |
186 |
$8K |
| D1120 |
Prophylaxis - child |
82 |
82 |
$4K |
| D1206 |
Topical application of fluoride varnish |
108 |
108 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
51 |
51 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
213 |
210 |
$1K |
| D0274 |
Bitewings - four radiographic images |
58 |
58 |
$696.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
72 |
72 |
$312.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$120.00 |