| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
122 |
121 |
$6K |
| D8670 |
Periodic orthodontic treatment visit |
73 |
57 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
168 |
166 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
160 |
158 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
54 |
30 |
$4K |
| D1110 |
Prophylaxis - adult |
59 |
58 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
241 |
137 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
155 |
152 |
$3K |
| D0272 |
Bitewings - two radiographic images |
85 |
84 |
$2K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$2K |