| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
383 |
383 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
374 |
374 |
$12K |
| D0272 |
Bitewings - two radiographic images |
260 |
260 |
$4K |
| D1206 |
Topical application of fluoride varnish |
149 |
149 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
321 |
321 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
252 |
252 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
349 |
349 |
$2K |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$1K |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$589.13 |
| D1330 |
|
49 |
49 |
$0.00 |
| D0603 |
|
16 |
16 |
$0.00 |