| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
811 |
810 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
779 |
779 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
572 |
572 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
127 |
126 |
$4K |
| D1206 |
Topical application of fluoride varnish |
226 |
225 |
$4K |
| D0272 |
Bitewings - two radiographic images |
189 |
189 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
199 |
197 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
196 |
173 |
$2K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$354.84 |