| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,960 |
1,960 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
3,059 |
3,059 |
$70K |
| D1120 |
Prophylaxis - child |
1,884 |
1,884 |
$65K |
| D0274 |
Bitewings - four radiographic images |
1,969 |
1,969 |
$53K |
| D1206 |
Topical application of fluoride varnish |
3,141 |
3,141 |
$51K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
391 |
220 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,366 |
1,366 |
$25K |
| D0240 |
|
1,288 |
1,278 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,369 |
1,355 |
$17K |
| D0330 |
Panoramic radiographic image |
320 |
320 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
120 |
68 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
290 |
290 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
75 |
39 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
127 |
126 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
40 |
$4K |
| D1351 |
Sealant - per tooth |
73 |
15 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
70 |
70 |
$1K |