| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
464 |
464 |
$10K |
| D0272 |
Bitewings - two radiographic images |
387 |
387 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
461 |
461 |
$5K |
| D0330 |
Panoramic radiographic image |
156 |
156 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
267 |
267 |
$4K |
| D1120 |
Prophylaxis - child |
152 |
152 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
135 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
18 |
13 |
$450.60 |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$447.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$74.60 |