| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,838 |
1,835 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
1,988 |
1,988 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,005 |
2,000 |
$43K |
| D1110 |
Prophylaxis - adult |
590 |
589 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
242 |
170 |
$27K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
159 |
108 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
317 |
313 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
149 |
147 |
$11K |
| D0272 |
Bitewings - two radiographic images |
422 |
422 |
$9K |
| D0274 |
Bitewings - four radiographic images |
131 |
131 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
24 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
38 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
80 |
80 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$546.00 |