| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
759 |
758 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
775 |
773 |
$15K |
| D0272 |
Bitewings - two radiographic images |
524 |
521 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
248 |
245 |
$5K |
| D0330 |
Panoramic radiographic image |
117 |
117 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
136 |
136 |
$3K |
| D1120 |
Prophylaxis - child |
71 |
71 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
159 |
155 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
18 |
15 |
$901.11 |
| D0230 |
Intraoral - periapical each additional radiographic image |
42 |
27 |
$336.00 |