| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
222 |
218 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
238 |
233 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
221 |
217 |
$6K |
| D0274 |
Bitewings - four radiographic images |
73 |
73 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
191 |
190 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
155 |
154 |
$706.80 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$402.60 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$315.75 |
| D0272 |
Bitewings - two radiographic images |
23 |
23 |
$216.20 |