| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,662 |
2,660 |
$211K |
| D0120 |
Periodic oral evaluation - established patient |
3,552 |
3,552 |
$152K |
| D0274 |
Bitewings - four radiographic images |
1,697 |
1,697 |
$94K |
| D1120 |
Prophylaxis - child |
1,508 |
1,508 |
$79K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
493 |
292 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
771 |
769 |
$46K |
| D0140 |
Limited oral evaluation - problem focused |
666 |
645 |
$39K |
| D1206 |
Topical application of fluoride varnish |
680 |
680 |
$26K |
| D0330 |
Panoramic radiographic image |
247 |
247 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
905 |
875 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
162 |
99 |
$22K |
| D2140 |
|
181 |
111 |
$19K |
| D0272 |
Bitewings - two radiographic images |
483 |
483 |
$18K |
| D2331 |
|
41 |
26 |
$6K |
| D1330 |
|
147 |
145 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
28 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
138 |
68 |
$3K |