| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
331 |
331 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
392 |
391 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
63 |
38 |
$4K |
| D0330 |
Panoramic radiographic image |
86 |
86 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
117 |
117 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
162 |
162 |
$2K |
| D0274 |
Bitewings - four radiographic images |
90 |
90 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
82 |
82 |
$2K |
| D2160 |
|
17 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$360.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$177.65 |