| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
816 |
795 |
$20.76 |
| D0230 |
Intraoral - periapical each additional radiographic image |
213 |
175 |
$6.00 |
| D0140 |
Limited oral evaluation - problem focused |
86 |
85 |
$0.00 |
| D1330 |
|
87 |
87 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
32 |
32 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$0.00 |
| D0270 |
|
44 |
43 |
$0.00 |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
39 |
37 |
$0.00 |
| D1110 |
Prophylaxis - adult |
14 |
13 |
$0.00 |
| D1999 |
|
31 |
30 |
$0.00 |