| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
407 |
326 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
147 |
136 |
$17K |
| D1110 |
Prophylaxis - adult |
239 |
224 |
$3K |
| D0274 |
Bitewings - four radiographic images |
281 |
269 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
33 |
13 |
$416.64 |
| D0330 |
Panoramic radiographic image |
43 |
43 |
$250.96 |
| D1206 |
Topical application of fluoride varnish |
29 |
29 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
13 |
$0.00 |