| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
490 |
451 |
$10K |
| D1206 |
Topical application of fluoride varnish |
559 |
400 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
244 |
236 |
$7K |
| D0272 |
Bitewings - two radiographic images |
57 |
49 |
$463.05 |
| D1999 |
|
48 |
31 |
$435.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
13 |
$423.90 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
12 |
$219.96 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
28 |
$207.46 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
15 |
$28.44 |
| D0603 |
|
25 |
25 |
$0.00 |