| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
298 |
298 |
$10K |
| D0274 |
Bitewings - four radiographic images |
304 |
304 |
$8K |
| D9110 |
|
126 |
125 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
154 |
154 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
158 |
157 |
$3K |
| D0330 |
Panoramic radiographic image |
72 |
71 |
$2K |
| D1120 |
Prophylaxis - child |
41 |
41 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
65 |
65 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
147 |
142 |
$1K |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$601.00 |
| D1330 |
|
51 |
51 |
$565.08 |