| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
327 |
304 |
$12K |
| D0330 |
Panoramic radiographic image |
75 |
71 |
$8K |
| D1120 |
Prophylaxis - child |
187 |
170 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
121 |
103 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
149 |
140 |
$6K |
| D0274 |
Bitewings - four radiographic images |
121 |
107 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
174 |
165 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
33 |
13 |
$3K |
| D2140 |
|
41 |
15 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
84 |
62 |
$3K |
| D1110 |
Prophylaxis - adult |
14 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
47 |
41 |
$1K |