| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,454 |
1,451 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
1,735 |
1,735 |
$44K |
| D1206 |
Topical application of fluoride varnish |
2,118 |
2,116 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,048 |
1,048 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
613 |
613 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,645 |
1,615 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,828 |
1,090 |
$15K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
238 |
134 |
$12K |
| D1120 |
Prophylaxis - child |
310 |
310 |
$12K |
| D4341 |
|
113 |
37 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
636 |
635 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
132 |
89 |
$9K |
| D0603 |
|
676 |
676 |
$7K |
| D1330 |
|
831 |
831 |
$7K |
| D4910 |
|
101 |
101 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
185 |
180 |
$6K |
| D2140 |
|
109 |
74 |
$4K |
| D1351 |
Sealant - per tooth |
88 |
19 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
57 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
24 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
13 |
$2K |
| D2160 |
|
18 |
15 |
$1K |
| D0601 |
|
88 |
88 |
$891.00 |
| D0272 |
Bitewings - two radiographic images |
32 |
32 |
$580.00 |