| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
64 |
58 |
$2K |
| D1110 |
Prophylaxis - adult |
40 |
37 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
93 |
83 |
$781.16 |
| D0274 |
Bitewings - four radiographic images |
60 |
56 |
$720.99 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
28 |
$681.04 |
| D1206 |
Topical application of fluoride varnish |
34 |
29 |
$631.11 |
| D0330 |
Panoramic radiographic image |
14 |
13 |
$546.48 |
| D1208 |
Topical application of fluoride, excluding varnish |
48 |
45 |
$492.57 |
| D0230 |
Intraoral - periapical each additional radiographic image |
105 |
75 |
$209.01 |
| D1330 |
|
19 |
19 |
$0.00 |