| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
825 |
727 |
$27K |
| D1120 |
Prophylaxis - child |
379 |
352 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
587 |
549 |
$17K |
| D1110 |
Prophylaxis - adult |
219 |
212 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
372 |
353 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
277 |
269 |
$4K |
| D1206 |
Topical application of fluoride varnish |
55 |
54 |
$2K |
| D0274 |
Bitewings - four radiographic images |
19 |
18 |
$799.00 |
| D0272 |
Bitewings - two radiographic images |
18 |
18 |
$582.30 |
| D1999 |
|
17 |
15 |
$0.00 |
| D0602 |
|
879 |
821 |
$0.00 |