| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
236 |
236 |
$9K |
| D1206 |
Topical application of fluoride varnish |
225 |
225 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
195 |
195 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
268 |
65 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
89 |
89 |
$1K |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$650.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$630.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$300.00 |