| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
629 |
610 |
$20K |
| D0272 |
Bitewings - two radiographic images |
329 |
316 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
271 |
267 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
182 |
164 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
50 |
29 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
103 |
103 |
$691.60 |
| D2140 |
|
20 |
14 |
$432.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$351.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$194.40 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$140.40 |
| D1999 |
|
212 |
201 |
$0.00 |