| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,092 |
1,092 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
1,860 |
1,860 |
$72K |
| D0274 |
Bitewings - four radiographic images |
814 |
814 |
$39K |
| D0220 |
Intraoral - periapical first radiographic image |
888 |
888 |
$27K |
| D1120 |
Prophylaxis - child |
292 |
292 |
$16K |
| D0272 |
Bitewings - two radiographic images |
331 |
331 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
449 |
449 |
$9K |
| D0330 |
Panoramic radiographic image |
134 |
134 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
16 |
15 |
$2K |
| D1206 |
Topical application of fluoride varnish |
28 |
28 |
$1K |
| D1330 |
|
1,371 |
1,371 |
$0.00 |