| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,229 |
3,226 |
$176K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,495 |
621 |
$126K |
| D0120 |
Periodic oral evaluation - established patient |
3,547 |
3,543 |
$100K |
| D0274 |
Bitewings - four radiographic images |
2,025 |
2,022 |
$70K |
| D0330 |
Panoramic radiographic image |
1,078 |
1,072 |
$52K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
428 |
281 |
$43K |
| D4341 |
|
934 |
361 |
$43K |
| D8670 |
Periodic orthodontic treatment visit |
146 |
144 |
$32K |
| D1120 |
Prophylaxis - child |
693 |
693 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,252 |
1,251 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
392 |
392 |
$12K |
| D2160 |
|
79 |
40 |
$8K |
| D9110 |
|
159 |
151 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
27 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
153 |
148 |
$2K |
| D0272 |
Bitewings - two radiographic images |
34 |
34 |
$712.90 |
| D1999 |
|
160 |
148 |
$0.00 |