| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
883 |
882 |
$21K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
379 |
106 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
1,235 |
1,235 |
$16K |
| D4342 |
|
430 |
149 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
810 |
810 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
167 |
167 |
$6K |
| D0272 |
Bitewings - two radiographic images |
591 |
591 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
339 |
339 |
$2K |
| D0274 |
Bitewings - four radiographic images |
104 |
104 |
$1K |
| D2140 |
|
19 |
12 |
$827.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$193.33 |
| D1999 |
|
76 |
73 |
$0.00 |
| D1310 |
|
16 |
16 |
$0.00 |