| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
477 |
477 |
$41K |
| D1120 |
Prophylaxis - child |
316 |
316 |
$21K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
151 |
89 |
$7K |
| D1351 |
Sealant - per tooth |
105 |
34 |
$804.37 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$750.58 |
| D0120 |
Periodic oral evaluation - established patient |
818 |
818 |
$521.23 |
| D0274 |
Bitewings - four radiographic images |
460 |
460 |
$117.16 |
| D1208 |
Topical application of fluoride, excluding varnish |
558 |
558 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
246 |
246 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
154 |
154 |
$0.00 |