| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,237 |
1,234 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,649 |
1,645 |
$32K |
| D1120 |
Prophylaxis - child |
497 |
496 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
628 |
622 |
$12K |
| D0274 |
Bitewings - four radiographic images |
403 |
399 |
$11K |
| D0272 |
Bitewings - two radiographic images |
657 |
654 |
$10K |
| D0330 |
Panoramic radiographic image |
285 |
282 |
$10K |
| D2330 |
|
207 |
152 |
$10K |
| D1206 |
Topical application of fluoride varnish |
466 |
465 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
130 |
107 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
410 |
409 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
128 |
99 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
247 |
242 |
$2K |
| D9110 |
|
43 |
42 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
13 |
12 |
$715.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$662.64 |
| D1330 |
|
44 |
44 |
$487.52 |
| D1310 |
|
44 |
44 |
$478.28 |