| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
25 |
25 |
$440.00 |
| D0120 |
Periodic oral evaluation - established patient |
27 |
27 |
$380.00 |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$306.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$240.00 |
| D0220 |
Intraoral - periapical first radiographic image |
74 |
72 |
$232.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$220.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$200.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$180.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
42 |
42 |
$117.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$78.00 |