| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
36 |
36 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
31 |
31 |
$761.80 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$589.40 |
| D1208 |
Topical application of fluoride, excluding varnish |
23 |
23 |
$575.70 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$413.10 |
| D0210 |
Intraoral - complete series of radiographic images |
23 |
23 |
$378.60 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$259.20 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$226.00 |
| D0272 |
Bitewings - two radiographic images |
20 |
20 |
$182.30 |
| D0220 |
Intraoral - periapical first radiographic image |
18 |
18 |
$100.80 |