| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
597 |
498 |
$16K |
| D1999 |
|
980 |
820 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
277 |
258 |
$5K |
| D0272 |
Bitewings - two radiographic images |
365 |
318 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
324 |
237 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
71 |
43 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
114 |
102 |
$1K |
| D2140 |
|
37 |
27 |
$734.40 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$379.56 |
| D1120 |
Prophylaxis - child |
22 |
21 |
$291.60 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$70.20 |