| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
322 |
322 |
$26K |
| D1330 |
|
1,224 |
1,223 |
$22K |
| D1110 |
Prophylaxis - adult |
683 |
683 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
714 |
713 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,158 |
1,157 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
339 |
339 |
$3K |
| D1120 |
Prophylaxis - child |
251 |
251 |
$2K |
| D0272 |
Bitewings - two radiographic images |
324 |
324 |
$1K |
| D1206 |
Topical application of fluoride varnish |
33 |
33 |
$131.00 |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$0.00 |