| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
49 |
49 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
35 |
35 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
52 |
52 |
$985.58 |
| D0220 |
Intraoral - periapical first radiographic image |
45 |
45 |
$533.68 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$493.20 |
| D0120 |
Periodic oral evaluation - established patient |
18 |
18 |
$427.07 |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
45 |
$426.03 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$341.24 |