| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,973 |
3,972 |
$216K |
| D0120 |
Periodic oral evaluation - established patient |
3,232 |
3,232 |
$89K |
| D1120 |
Prophylaxis - child |
1,342 |
1,342 |
$56K |
| D0274 |
Bitewings - four radiographic images |
1,938 |
1,938 |
$56K |
| D2160 |
|
213 |
176 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
691 |
691 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
237 |
237 |
$14K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
156 |
130 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
927 |
913 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
794 |
794 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
209 |
208 |
$3K |
| D0272 |
Bitewings - two radiographic images |
119 |
119 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
57 |
57 |
$569.23 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$349.50 |