| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
117 |
112 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
124 |
118 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
120 |
115 |
$3K |
| D0274 |
Bitewings - four radiographic images |
51 |
48 |
$794.30 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$231.55 |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
38 |
$212.80 |
| D0272 |
Bitewings - two radiographic images |
22 |
21 |
$197.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
13 |
$106.40 |