| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
175 |
175 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
126 |
126 |
$2K |
| D1206 |
Topical application of fluoride varnish |
96 |
96 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
78 |
78 |
$1K |
| D0272 |
Bitewings - two radiographic images |
41 |
41 |
$410.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$368.90 |
| D0240 |
|
17 |
14 |
$288.00 |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
37 |
$190.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$85.00 |