| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,868 |
1,868 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
2,389 |
2,389 |
$42K |
| D0274 |
Bitewings - four radiographic images |
2,158 |
2,158 |
$37K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
660 |
464 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,424 |
2,411 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
2,727 |
2,691 |
$20K |
| D2160 |
|
91 |
78 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
344 |
344 |
$4K |
| D1120 |
Prophylaxis - child |
68 |
68 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
750 |
742 |
$616.78 |
| D9110 |
|
13 |
12 |
$192.88 |
| D1999 |
|
12 |
12 |
$0.00 |