| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
357 |
344 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
564 |
547 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
53 |
53 |
$8K |
| D1120 |
Prophylaxis - child |
139 |
136 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
358 |
349 |
$4K |
| D0274 |
Bitewings - four radiographic images |
122 |
119 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
322 |
306 |
$3K |
| D1351 |
Sealant - per tooth |
118 |
26 |
$3K |
| D1110 |
Prophylaxis - adult |
48 |
45 |
$2K |
| D1330 |
|
74 |
66 |
$673.75 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$591.36 |
| D0601 |
|
339 |
325 |
$0.00 |
| D0603 |
|
80 |
76 |
$0.00 |