| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,867 |
2,867 |
$145K |
| D0120 |
Periodic oral evaluation - established patient |
3,068 |
3,068 |
$71K |
| D0274 |
Bitewings - four radiographic images |
2,001 |
2,001 |
$55K |
| D1206 |
Topical application of fluoride varnish |
2,451 |
2,450 |
$40K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
456 |
272 |
$36K |
| D1120 |
Prophylaxis - child |
752 |
752 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
559 |
559 |
$22K |
| D0330 |
Panoramic radiographic image |
442 |
442 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
168 |
105 |
$18K |
| D0272 |
Bitewings - two radiographic images |
931 |
931 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
380 |
369 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
145 |
145 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
41 |
$2K |