| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,043 |
2,043 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
2,488 |
2,488 |
$67K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,178 |
1,178 |
$27K |
| D0330 |
Panoramic radiographic image |
379 |
379 |
$26K |
| D1110 |
Prophylaxis - adult |
456 |
456 |
$23K |
| D0272 |
Bitewings - two radiographic images |
932 |
931 |
$22K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
115 |
81 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
39 |
$7K |
| D2140 |
|
45 |
25 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$3K |