| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,598 |
2,595 |
$116K |
| D0120 |
Periodic oral evaluation - established patient |
3,742 |
3,738 |
$91K |
| D1120 |
Prophylaxis - child |
1,438 |
1,438 |
$59K |
| D0272 |
Bitewings - two radiographic images |
2,831 |
2,829 |
$39K |
| D0220 |
Intraoral - periapical first radiographic image |
3,493 |
3,485 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,213 |
3,203 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
217 |
92 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
972 |
972 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
162 |
90 |
$11K |
| D1206 |
Topical application of fluoride varnish |
133 |
133 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
89 |
89 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
126 |
126 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
37 |
25 |
$3K |
| D2140 |
|
17 |
12 |
$1K |