| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,577 |
1,576 |
$122K |
| D1354 |
|
3,491 |
896 |
$113K |
| D0330 |
Panoramic radiographic image |
915 |
914 |
$85K |
| D0140 |
Limited oral evaluation - problem focused |
1,869 |
1,787 |
$84K |
| D1120 |
Prophylaxis - child |
1,329 |
1,329 |
$72K |
| D1206 |
Topical application of fluoride varnish |
1,730 |
1,728 |
$62K |
| D0274 |
Bitewings - four radiographic images |
1,196 |
1,195 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
1,459 |
1,457 |
$62K |
| D0220 |
Intraoral - periapical first radiographic image |
1,089 |
1,072 |
$22K |
| D1330 |
|
374 |
374 |
$17K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
104 |
75 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
131 |
82 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
667 |
505 |
$11K |
| D1310 |
|
229 |
229 |
$8K |
| D1351 |
Sealant - per tooth |
176 |
30 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
29 |
$5K |
| D2140 |
|
45 |
26 |
$4K |
| D2330 |
|
18 |
12 |
$2K |
| D9410 |
|
31 |
31 |
$2K |
| D3120 |
|
121 |
83 |
$0.00 |
| D0190 |
|
85 |
85 |
$0.00 |