| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0367 |
|
39 |
38 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
337 |
328 |
$4K |
| D1120 |
Prophylaxis - child |
63 |
61 |
$3K |
| D1206 |
Topical application of fluoride varnish |
100 |
98 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
106 |
103 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
60 |
55 |
$2K |
| D0330 |
Panoramic radiographic image |
64 |
62 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
187 |
167 |
$1K |
| D0274 |
Bitewings - four radiographic images |
45 |
43 |
$728.31 |
| D0120 |
Periodic oral evaluation - established patient |
27 |
25 |
$465.36 |
| D9215 |
|
51 |
51 |
$307.50 |