| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
200 |
199 |
$5K |
| D1120 |
Prophylaxis - child |
130 |
130 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
283 |
150 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
161 |
159 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
155 |
155 |
$2K |
| D0272 |
Bitewings - two radiographic images |
50 |
50 |
$1K |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$878.08 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$449.93 |
| D1206 |
Topical application of fluoride varnish |
57 |
56 |
$411.60 |
| D0602 |
|
37 |
37 |
$0.00 |
| D0603 |
|
193 |
191 |
$0.00 |