| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,291 |
1,233 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,936 |
1,861 |
$44K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
537 |
309 |
$27K |
| D0274 |
Bitewings - four radiographic images |
1,235 |
1,178 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
839 |
675 |
$24K |
| D0330 |
Panoramic radiographic image |
676 |
656 |
$23K |
| D1120 |
Prophylaxis - child |
442 |
431 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
883 |
858 |
$11K |
| D2160 |
|
153 |
105 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,153 |
1,070 |
$9K |
| D1351 |
Sealant - per tooth |
174 |
46 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
408 |
221 |
$2K |
| D2140 |
|
17 |
12 |
$615.60 |
| D0272 |
Bitewings - two radiographic images |
19 |
19 |
$316.68 |