| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
474 |
406 |
$11K |
| D0330 |
Panoramic radiographic image |
232 |
189 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
313 |
277 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
110 |
51 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
146 |
130 |
$3K |
| D2140 |
|
103 |
50 |
$2K |
| D0272 |
Bitewings - two radiographic images |
169 |
151 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
108 |
95 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
48 |
28 |
$1K |
| D1120 |
Prophylaxis - child |
31 |
31 |
$512.40 |