| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
105 |
105 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
122 |
121 |
$3K |
| D1110 |
Prophylaxis - adult |
47 |
47 |
$2K |
| D1206 |
Topical application of fluoride varnish |
89 |
89 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$1K |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$901.57 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
20 |
20 |
$900.00 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$675.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
19 |
19 |
$341.41 |