| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
28 |
27 |
$879.00 |
| D0120 |
Periodic oral evaluation - established patient |
31 |
28 |
$674.20 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
16 |
$459.91 |
| D1208 |
Topical application of fluoride, excluding varnish |
22 |
21 |
$429.70 |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
38 |
$373.12 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$359.71 |
| D0272 |
Bitewings - two radiographic images |
15 |
14 |
$342.74 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
12 |
$323.32 |
| D0230 |
Intraoral - periapical each additional radiographic image |
64 |
38 |
$309.80 |
| D0274 |
Bitewings - four radiographic images |
22 |
19 |
$228.42 |