| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,105 |
2,103 |
$112K |
| D0120 |
Periodic oral evaluation - established patient |
3,353 |
3,349 |
$91K |
| D1120 |
Prophylaxis - child |
1,428 |
1,426 |
$56K |
| D0274 |
Bitewings - four radiographic images |
1,541 |
1,539 |
$51K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,081 |
2,079 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
272 |
189 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
273 |
171 |
$14K |
| D0330 |
Panoramic radiographic image |
269 |
269 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
114 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
34 |
25 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
166 |
156 |
$2K |
| D1354 |
|
47 |
16 |
$2K |
| D1355 |
|
50 |
18 |
$926.50 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$334.40 |