| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
408 |
408 |
$13K |
| D1206 |
Topical application of fluoride varnish |
581 |
577 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
331 |
331 |
$8K |
| D1110 |
Prophylaxis - adult |
126 |
126 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
189 |
189 |
$5K |
| D0272 |
Bitewings - two radiographic images |
263 |
263 |
$5K |
| D1310 |
|
361 |
361 |
$5K |
| D1330 |
|
278 |
278 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
273 |
273 |
$3K |
| D0274 |
Bitewings - four radiographic images |
89 |
89 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
240 |
217 |
$3K |
| D1320 |
|
71 |
71 |
$586.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
20 |
20 |
$414.00 |
| D0603 |
|
83 |
83 |
$0.00 |