| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
173 |
144 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
50 |
50 |
$1K |
| D0330 |
Panoramic radiographic image |
18 |
17 |
$362.04 |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
27 |
$297.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
70 |
58 |
$246.87 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
17 |
$231.70 |
| D0274 |
Bitewings - four radiographic images |
21 |
20 |
$147.21 |
| D1330 |
|
41 |
39 |
$51.00 |