| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
445 |
428 |
$10K |
| D0272 |
Bitewings - two radiographic images |
374 |
363 |
$5K |
| D0330 |
Panoramic radiographic image |
172 |
168 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
390 |
377 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
219 |
216 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
170 |
164 |
$2K |
| D1120 |
Prophylaxis - child |
78 |
76 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
89 |
83 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
33 |
27 |
$785.50 |
| D0220 |
Intraoral - periapical first radiographic image |
93 |
88 |
$468.00 |