| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,341 |
1,330 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
2,012 |
1,999 |
$38K |
| D1120 |
Prophylaxis - child |
172 |
172 |
$4K |
| D0274 |
Bitewings - four radiographic images |
129 |
129 |
$4K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
53 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
15 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
63 |
62 |
$715.34 |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$496.33 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$381.83 |
| D1999 |
|
277 |
272 |
$0.00 |