| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
144 |
144 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
193 |
193 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
134 |
134 |
$4K |
| D0274 |
Bitewings - four radiographic images |
98 |
98 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
162 |
162 |
$1K |
| D1110 |
Prophylaxis - adult |
19 |
19 |
$919.22 |
| D0230 |
Intraoral - periapical each additional radiographic image |
144 |
144 |
$810.91 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$312.96 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$229.44 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$133.08 |