| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
299 |
297 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
187 |
186 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
131 |
130 |
$2K |
| D1206 |
Topical application of fluoride varnish |
99 |
99 |
$1K |
| D0272 |
Bitewings - two radiographic images |
128 |
126 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$316.20 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$293.54 |
| D0220 |
Intraoral - periapical first radiographic image |
51 |
51 |
$250.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
12 |
$156.50 |