| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
226 |
200 |
$4K |
| D1120 |
Prophylaxis - child |
202 |
181 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
302 |
274 |
$2K |
| D1110 |
Prophylaxis - adult |
49 |
49 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
42 |
$1K |
| D0274 |
Bitewings - four radiographic images |
46 |
45 |
$726.60 |
| D0220 |
Intraoral - periapical first radiographic image |
110 |
110 |
$684.21 |
| D0272 |
Bitewings - two radiographic images |
64 |
64 |
$672.15 |
| D0230 |
Intraoral - periapical each additional radiographic image |
95 |
93 |
$541.43 |
| D0602 |
|
130 |
100 |
$0.00 |
| D0603 |
|
65 |
65 |
$0.00 |
| D0601 |
|
14 |
14 |
$0.00 |