| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
808 |
730 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
398 |
309 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
103 |
89 |
$875.42 |
| D1208 |
Topical application of fluoride, excluding varnish |
79 |
79 |
$688.03 |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$277.23 |
| D0120 |
Periodic oral evaluation - established patient |
28 |
28 |
$275.43 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$267.69 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$243.26 |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$235.64 |
| D1206 |
Topical application of fluoride varnish |
41 |
41 |
$61.56 |
| D1999 |
|
284 |
204 |
$0.00 |