| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
567 |
567 |
$16K |
| D1999 |
|
873 |
817 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,122 |
384 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
389 |
389 |
$6K |
| D0272 |
Bitewings - two radiographic images |
342 |
342 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
167 |
167 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
380 |
380 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
34 |
28 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
44 |
$652.52 |
| D1120 |
Prophylaxis - child |
18 |
14 |
$280.00 |