| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,370 |
1,340 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
2,432 |
2,341 |
$45K |
| D1120 |
Prophylaxis - child |
568 |
535 |
$16K |
| D0274 |
Bitewings - four radiographic images |
590 |
579 |
$14K |
| D1206 |
Topical application of fluoride varnish |
290 |
276 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
37 |
26 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
125 |
122 |
$1K |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$895.84 |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$414.01 |