| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
204 |
203 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
206 |
206 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
191 |
190 |
$5K |
| D0274 |
Bitewings - four radiographic images |
86 |
85 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
75 |
74 |
$414.40 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$252.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
34 |
30 |
$155.80 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$122.20 |