| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
338 |
337 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
289 |
289 |
$11K |
| D1120 |
Prophylaxis - child |
200 |
200 |
$10K |
| D1110 |
Prophylaxis - adult |
109 |
109 |
$8K |
| D0272 |
Bitewings - two radiographic images |
145 |
145 |
$6K |
| D0274 |
Bitewings - four radiographic images |
122 |
121 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
62 |
$4K |
| D0330 |
Panoramic radiographic image |
45 |
44 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
15 |
12 |
$3K |
| D2140 |
|
18 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
104 |
82 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
107 |
104 |
$2K |