| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
768 |
766 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
965 |
961 |
$16K |
| D0330 |
Panoramic radiographic image |
377 |
377 |
$13K |
| D1120 |
Prophylaxis - child |
547 |
545 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
543 |
541 |
$8K |
| D0274 |
Bitewings - four radiographic images |
450 |
446 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
168 |
168 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
820 |
813 |
$4K |
| D2140 |
|
88 |
37 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
627 |
619 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
126 |
125 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
20 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$160.00 |