| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,848 |
1,848 |
$82K |
| D0120 |
Periodic oral evaluation - established patient |
2,133 |
2,132 |
$53K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,555 |
1,551 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,573 |
1,562 |
$19K |
| D0274 |
Bitewings - four radiographic images |
439 |
439 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
71 |
71 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
23 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
39 |
39 |
$508.00 |