| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
457 |
454 |
$16K |
| D0274 |
Bitewings - four radiographic images |
485 |
481 |
$13K |
| D9110 |
|
347 |
342 |
$11K |
| D0330 |
Panoramic radiographic image |
209 |
207 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
367 |
361 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
305 |
305 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
60 |
40 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
328 |
313 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
84 |
84 |
$2K |
| D1120 |
Prophylaxis - child |
40 |
40 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$192.00 |