| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
129 |
127 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
103 |
103 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
131 |
129 |
$2K |
| D0274 |
Bitewings - four radiographic images |
128 |
127 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
96 |
93 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
191 |
188 |
$683.19 |
| D1110 |
Prophylaxis - adult |
38 |
38 |
$600.45 |
| D0230 |
Intraoral - periapical each additional radiographic image |
217 |
177 |
$498.71 |
| D1206 |
Topical application of fluoride varnish |
77 |
76 |
$12.89 |