| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
917 |
916 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
715 |
715 |
$19K |
| D0274 |
Bitewings - four radiographic images |
272 |
272 |
$10K |
| D1206 |
Topical application of fluoride varnish |
281 |
280 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
480 |
480 |
$7K |
| D1110 |
Prophylaxis - adult |
85 |
85 |
$4K |
| D0330 |
Panoramic radiographic image |
65 |
64 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
25 |
25 |
$858.20 |
| D0272 |
Bitewings - two radiographic images |
37 |
36 |
$680.20 |
| D0140 |
Limited oral evaluation - problem focused |
35 |
35 |
$588.30 |
| D1310 |
|
56 |
56 |
$0.00 |