| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
332 |
314 |
$3K |
| D0274 |
Bitewings - four radiographic images |
145 |
143 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
337 |
290 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
117 |
117 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
183 |
183 |
$3K |
| D1110 |
Prophylaxis - adult |
47 |
47 |
$2K |
| D1120 |
Prophylaxis - child |
15 |
15 |
$356.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$308.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$196.00 |