| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,103 |
3,095 |
$166K |
| D0120 |
Periodic oral evaluation - established patient |
4,063 |
4,055 |
$111K |
| D0274 |
Bitewings - four radiographic images |
2,007 |
2,001 |
$59K |
| D1120 |
Prophylaxis - child |
1,235 |
1,235 |
$51K |
| D0330 |
Panoramic radiographic image |
703 |
701 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,596 |
1,593 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
919 |
910 |
$13K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
127 |
115 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
822 |
819 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
333 |
330 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
278 |
276 |
$9K |
| D2140 |
|
55 |
50 |
$3K |
| D1351 |
Sealant - per tooth |
12 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
107 |
107 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
25 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$358.50 |