| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,421 |
2,421 |
$184K |
| D0120 |
Periodic oral evaluation - established patient |
3,788 |
3,754 |
$145K |
| D0274 |
Bitewings - four radiographic images |
1,937 |
1,937 |
$101K |
| D0220 |
Intraoral - periapical first radiographic image |
1,857 |
1,848 |
$51K |
| D1120 |
Prophylaxis - child |
608 |
608 |
$34K |
| D1206 |
Topical application of fluoride varnish |
638 |
638 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
202 |
150 |
$20K |
| D0272 |
Bitewings - two radiographic images |
507 |
507 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
896 |
486 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
167 |
120 |
$10K |
| D0330 |
Panoramic radiographic image |
178 |
178 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
341 |
341 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
14 |
12 |
$1K |
| 90846 |
Family psychotherapy without the patient present, 50 minutes |
14 |
12 |
$1K |
| D1330 |
|
3,682 |
3,663 |
$105.00 |