| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
820 |
816 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
796 |
793 |
$22K |
| D1206 |
Topical application of fluoride varnish |
774 |
771 |
$12K |
| D0272 |
Bitewings - two radiographic images |
272 |
269 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
34 |
33 |
$942.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
34 |
34 |
$510.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$468.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$448.56 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$124.80 |