| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
116 |
116 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
113 |
113 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
136 |
136 |
$3K |
| D0330 |
Panoramic radiographic image |
33 |
33 |
$2K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$448.56 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$390.00 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$386.75 |
| D0230 |
Intraoral - periapical each additional radiographic image |
27 |
13 |
$263.25 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$169.00 |