| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1999 |
|
653 |
631 |
$10K |
| D1110 |
Prophylaxis - adult |
351 |
345 |
$9K |
| D0272 |
Bitewings - two radiographic images |
258 |
256 |
$4K |
| D0330 |
Panoramic radiographic image |
127 |
122 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
121 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
122 |
105 |
$881.03 |
| D0220 |
Intraoral - periapical first radiographic image |
109 |
108 |
$794.85 |
| D1208 |
Topical application of fluoride, excluding varnish |
31 |
31 |
$420.00 |
| D0120 |
Periodic oral evaluation - established patient |
26 |
26 |
$400.92 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$220.80 |