| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
80 |
80 |
$3K |
| D1120 |
Prophylaxis - child |
53 |
53 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
246 |
232 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
258 |
170 |
$2K |
| D1206 |
Topical application of fluoride varnish |
44 |
44 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
20 |
20 |
$1K |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$689.39 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$557.65 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$412.24 |