| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
27 |
27 |
$825.39 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
20 |
20 |
$671.60 |
| D1208 |
Topical application of fluoride, excluding varnish |
34 |
34 |
$593.64 |
| D0274 |
Bitewings - four radiographic images |
19 |
19 |
$539.03 |
| D0220 |
Intraoral - periapical first radiographic image |
46 |
46 |
$502.32 |
| D0120 |
Periodic oral evaluation - established patient |
22 |
22 |
$480.26 |
| D0230 |
Intraoral - periapical each additional radiographic image |
43 |
43 |
$401.12 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
12 |
$397.18 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$275.10 |