| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4346 |
|
243 |
242 |
$187.37 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
216 |
215 |
$132.62 |
| D0330 |
Panoramic radiographic image |
329 |
328 |
$117.97 |
| D0220 |
Intraoral - periapical first radiographic image |
554 |
548 |
$53.58 |
| D1208 |
Topical application of fluoride, excluding varnish |
162 |
161 |
$48.00 |
| D0274 |
Bitewings - four radiographic images |
385 |
384 |
$21.00 |
| D0340 |
|
40 |
40 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
102 |
102 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
16 |
$0.00 |