| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
636 |
620 |
$21K |
| D0330 |
Panoramic radiographic image |
277 |
270 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
604 |
585 |
$10K |
| D0274 |
Bitewings - four radiographic images |
520 |
504 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
180 |
176 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
20 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
153 |
148 |
$715.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$158.06 |