| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
751 |
746 |
$63K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,852 |
1,880 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,822 |
1,810 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
391 |
388 |
$25K |
| D1120 |
Prophylaxis - child |
546 |
546 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,532 |
1,522 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
225 |
225 |
$13K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
159 |
92 |
$11K |
| D0350 |
|
684 |
305 |
$7K |
| D1351 |
Sealant - per tooth |
110 |
28 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
69 |
$824.00 |