| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,384 |
1,379 |
$89K |
| D1206 |
Topical application of fluoride varnish |
1,683 |
1,678 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,446 |
1,443 |
$56K |
| D0274 |
Bitewings - four radiographic images |
980 |
977 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
879 |
876 |
$43K |
| D0330 |
Panoramic radiographic image |
391 |
389 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
342 |
214 |
$35K |
| D1120 |
Prophylaxis - child |
722 |
721 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
351 |
219 |
$28K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
243 |
150 |
$25K |
| D1330 |
|
554 |
554 |
$21K |
| D2140 |
|
109 |
68 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
138 |
137 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
356 |
353 |
$6K |
| D0272 |
Bitewings - two radiographic images |
127 |
127 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
12 |
$206.64 |