| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
168 |
165 |
$16K |
| D0330 |
Panoramic radiographic image |
30 |
29 |
$604.09 |
| D0220 |
Intraoral - periapical first radiographic image |
182 |
174 |
$206.85 |
| D1208 |
Topical application of fluoride, excluding varnish |
177 |
174 |
$49.05 |
| D1120 |
Prophylaxis - child |
107 |
105 |
$41.62 |
| D0272 |
Bitewings - two radiographic images |
68 |
66 |
$26.76 |
| D0274 |
Bitewings - four radiographic images |
64 |
64 |
$20.26 |
| D0230 |
Intraoral - periapical each additional radiographic image |
178 |
173 |
$13.38 |
| D1330 |
|
174 |
171 |
$9.00 |
| D1110 |
Prophylaxis - adult |
43 |
43 |
$0.00 |
| D0340 |
|
39 |
38 |
$0.00 |