| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
415 |
388 |
$8K |
| D1206 |
Topical application of fluoride varnish |
365 |
337 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
152 |
145 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
226 |
221 |
$4K |
| D0330 |
Panoramic radiographic image |
64 |
64 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
151 |
151 |
$2K |
| D0272 |
Bitewings - two radiographic images |
230 |
209 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$409.56 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$140.00 |