| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
811 |
811 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,447 |
1,447 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,385 |
1,385 |
$22K |
| D1120 |
Prophylaxis - child |
441 |
441 |
$15K |
| D0274 |
Bitewings - four radiographic images |
332 |
332 |
$9K |
| D0272 |
Bitewings - two radiographic images |
230 |
230 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
33 |
24 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$1K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$1K |