| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,364 |
1,352 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
793 |
783 |
$40K |
| D1206 |
Topical application of fluoride varnish |
1,342 |
1,330 |
$16K |
| D2140 |
|
286 |
107 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
194 |
193 |
$12K |
| D0274 |
Bitewings - four radiographic images |
643 |
636 |
$10K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
78 |
38 |
$5K |
| D0350 |
|
400 |
136 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
838 |
403 |
$3K |
| D0330 |
Panoramic radiographic image |
49 |
49 |
$1K |