| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,027 |
3,027 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
4,029 |
4,026 |
$63K |
| D0274 |
Bitewings - four radiographic images |
2,113 |
2,112 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
3,640 |
3,612 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,021 |
2,015 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
185 |
185 |
$5K |
| D1120 |
Prophylaxis - child |
220 |
220 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
318 |
318 |
$3K |
| D9110 |
|
110 |
110 |
$1K |
| D2140 |
|
30 |
26 |
$791.28 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
15 |
14 |
$598.68 |