| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
142 |
142 |
$3K |
| D1120 |
Prophylaxis - child |
55 |
54 |
$3K |
| D1206 |
Topical application of fluoride varnish |
58 |
57 |
$2K |
| D1110 |
Prophylaxis - adult |
42 |
42 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
160 |
158 |
$1K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$1K |
| D0274 |
Bitewings - four radiographic images |
50 |
50 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
118 |
118 |
$770.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$540.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$240.00 |