| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
277 |
248 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
252 |
220 |
$6K |
| D0272 |
Bitewings - two radiographic images |
142 |
124 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
54 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
179 |
154 |
$3K |
| D1206 |
Topical application of fluoride varnish |
117 |
109 |
$2K |
| D0330 |
Panoramic radiographic image |
29 |
28 |
$2K |
| D0274 |
Bitewings - four radiographic images |
45 |
38 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
89 |
78 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
70 |
54 |
$683.61 |