| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,216 |
2,216 |
$142K |
| D0120 |
Periodic oral evaluation - established patient |
2,019 |
2,017 |
$64K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
364 |
349 |
$45K |
| D0330 |
Panoramic radiographic image |
974 |
974 |
$37K |
| D2160 |
|
239 |
219 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
708 |
708 |
$24K |
| D2331 |
|
149 |
134 |
$23K |
| D1120 |
Prophylaxis - child |
393 |
393 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
727 |
727 |
$11K |
| D9110 |
|
340 |
330 |
$11K |
| D0274 |
Bitewings - four radiographic images |
276 |
276 |
$9K |
| D1351 |
Sealant - per tooth |
62 |
61 |
$9K |
| D0272 |
Bitewings - two radiographic images |
434 |
434 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
55 |
$5K |
| D2140 |
|
57 |
55 |
$5K |
| D9310 |
|
71 |
71 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
104 |
104 |
$2K |