| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
393 |
393 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
292 |
292 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
281 |
281 |
$3K |
| D1206 |
Topical application of fluoride varnish |
111 |
111 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
102 |
102 |
$3K |
| D0272 |
Bitewings - two radiographic images |
159 |
159 |
$2K |
| D1110 |
Prophylaxis - adult |
35 |
35 |
$2K |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$467.36 |
| D0274 |
Bitewings - four radiographic images |
17 |
17 |
$415.91 |