| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,082 |
1,082 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,378 |
1,378 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
2,077 |
2,065 |
$23K |
| D0274 |
Bitewings - four radiographic images |
689 |
689 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
1,018 |
991 |
$15K |
| D1120 |
Prophylaxis - child |
344 |
344 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
880 |
880 |
$10K |
| D0272 |
Bitewings - two radiographic images |
724 |
724 |
$10K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
100 |
82 |
$6K |
| D0270 |
|
504 |
498 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
605 |
605 |
$3K |