| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
166 |
159 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
165 |
164 |
$4K |
| D1206 |
Topical application of fluoride varnish |
177 |
177 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
86 |
85 |
$2K |
| D1310 |
|
82 |
82 |
$818.00 |
| D1330 |
|
76 |
76 |
$730.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$355.90 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$208.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$126.16 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$111.44 |