| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
121 |
105 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
199 |
179 |
$4K |
| D1351 |
Sealant - per tooth |
167 |
30 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
245 |
222 |
$3K |
| D1120 |
Prophylaxis - child |
85 |
79 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
32 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
212 |
184 |
$1K |
| D1110 |
Prophylaxis - adult |
47 |
38 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
416 |
175 |
$834.63 |
| D0272 |
Bitewings - two radiographic images |
33 |
30 |
$308.70 |