| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
83 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
110 |
109 |
$2K |
| D1120 |
Prophylaxis - child |
81 |
81 |
$2K |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$600.00 |
| D0120 |
Periodic oral evaluation - established patient |
30 |
30 |
$495.32 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$416.88 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$150.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$55.00 |