| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
303 |
299 |
$10K |
| D2140 |
|
198 |
86 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
344 |
341 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
87 |
46 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
143 |
142 |
$4K |
| D0330 |
Panoramic radiographic image |
40 |
40 |
$2K |
| D1120 |
Prophylaxis - child |
75 |
74 |
$1K |
| D0272 |
Bitewings - two radiographic images |
114 |
114 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
73 |
72 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
79 |
$345.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$273.00 |