| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
119 |
114 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
92 |
87 |
$1K |
| D0274 |
Bitewings - four radiographic images |
53 |
51 |
$564.31 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$522.42 |
| D0230 |
Intraoral - periapical each additional radiographic image |
120 |
99 |
$390.88 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$288.15 |
| D0272 |
Bitewings - two radiographic images |
48 |
47 |
$182.89 |
| D1120 |
Prophylaxis - child |
98 |
94 |
$46.84 |
| D1206 |
Topical application of fluoride varnish |
83 |
81 |
$0.00 |
| D1110 |
Prophylaxis - adult |
18 |
17 |
$0.00 |