| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
307 |
307 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
292 |
292 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
272 |
272 |
$7K |
| D1110 |
Prophylaxis - adult |
115 |
115 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
119 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
272 |
271 |
$5K |
| D0274 |
Bitewings - four radiographic images |
65 |
65 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
239 |
236 |
$2K |
| D0272 |
Bitewings - two radiographic images |
46 |
46 |
$1K |
| D1206 |
Topical application of fluoride varnish |
29 |
29 |
$725.00 |