| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
999 |
882 |
$22K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
409 |
174 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
682 |
588 |
$10K |
| D0272 |
Bitewings - two radiographic images |
704 |
640 |
$9K |
| D0330 |
Panoramic radiographic image |
351 |
308 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
530 |
460 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
560 |
516 |
$6K |
| D2140 |
|
201 |
93 |
$5K |
| D1120 |
Prophylaxis - child |
291 |
245 |
$5K |
| D1351 |
Sealant - per tooth |
138 |
16 |
$2K |
| D2160 |
|
21 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
171 |
168 |
$942.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
192 |
189 |
$854.00 |
| D1999 |
|
19 |
12 |
$450.00 |