| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
265 |
235 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
275 |
245 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
89 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
98 |
98 |
$3K |
| D0272 |
Bitewings - two radiographic images |
194 |
168 |
$3K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$982.50 |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
40 |
$377.33 |
| D0230 |
Intraoral - periapical each additional radiographic image |
91 |
16 |
$219.36 |