| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
90 |
88 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
102 |
102 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
79 |
78 |
$2K |
| D0272 |
Bitewings - two radiographic images |
36 |
36 |
$1K |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$1K |
| D1206 |
Topical application of fluoride varnish |
27 |
25 |
$713.97 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$596.40 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$280.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$224.00 |