| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
148 |
145 |
$4K |
| D1120 |
Prophylaxis - child |
111 |
109 |
$4K |
| D1110 |
Prophylaxis - adult |
72 |
70 |
$3K |
| D0274 |
Bitewings - four radiographic images |
84 |
82 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
188 |
184 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
182 |
178 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
187 |
178 |
$2K |
| D0272 |
Bitewings - two radiographic images |
80 |
78 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
12 |
$423.84 |
| D0603 |
|
164 |
161 |
$0.00 |
| D0601 |
|
15 |
15 |
$0.00 |