| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,194 |
1,129 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,626 |
1,542 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,731 |
1,638 |
$30K |
| D1110 |
Prophylaxis - adult |
406 |
375 |
$15K |
| D0272 |
Bitewings - two radiographic images |
329 |
305 |
$7K |
| D0330 |
Panoramic radiographic image |
59 |
56 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
40 |
31 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
20 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
15 |
12 |
$455.28 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$130.88 |