| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
922 |
921 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,283 |
1,282 |
$26K |
| D0274 |
Bitewings - four radiographic images |
550 |
549 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,197 |
1,179 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
823 |
810 |
$5K |
| D1120 |
Prophylaxis - child |
131 |
131 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
295 |
295 |
$3K |
| D1999 |
|
21 |
21 |
$1K |
| D9110 |
|
52 |
52 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
15 |
12 |
$804.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$156.80 |