| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
733 |
732 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,119 |
1,118 |
$30K |
| D1120 |
Prophylaxis - child |
532 |
532 |
$19K |
| D1206 |
Topical application of fluoride varnish |
822 |
821 |
$18K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
172 |
93 |
$15K |
| D0274 |
Bitewings - four radiographic images |
423 |
422 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
79 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
79 |
79 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
197 |
193 |
$3K |
| D0272 |
Bitewings - two radiographic images |
102 |
102 |
$3K |