| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
341 |
341 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
449 |
448 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
340 |
340 |
$9K |
| D0274 |
Bitewings - four radiographic images |
139 |
137 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
279 |
275 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
262 |
252 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$573.76 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$121.99 |