| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,549 |
6,361 |
$229K |
| D0120 |
Periodic oral evaluation - established patient |
9,390 |
9,160 |
$169K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,067 |
1,203 |
$108K |
| D0274 |
Bitewings - four radiographic images |
2,763 |
2,685 |
$57K |
| D1120 |
Prophylaxis - child |
1,761 |
1,712 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
394 |
268 |
$20K |
| D1206 |
Topical application of fluoride varnish |
765 |
765 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
2,019 |
1,970 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
530 |
500 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
538 |
510 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
112 |
72 |
$6K |
| D0272 |
Bitewings - two radiographic images |
435 |
420 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
73 |
54 |
$4K |
| D2140 |
|
58 |
51 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$555.84 |