| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
801 |
709 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
531 |
482 |
$9K |
| D0330 |
Panoramic radiographic image |
95 |
54 |
$8K |
| D1206 |
Topical application of fluoride varnish |
309 |
288 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
102 |
57 |
$5K |
| D0272 |
Bitewings - two radiographic images |
160 |
126 |
$2K |
| D1120 |
Prophylaxis - child |
74 |
74 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
19 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
151 |
124 |
$763.86 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$220.00 |