| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,567 |
1,566 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
1,672 |
1,672 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,605 |
1,604 |
$40K |
| D1110 |
Prophylaxis - adult |
745 |
745 |
$38K |
| D0210 |
Intraoral - complete series of radiographic images |
410 |
410 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
569 |
569 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
484 |
471 |
$20K |
| D0274 |
Bitewings - four radiographic images |
405 |
405 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
607 |
601 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
41 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
95 |
94 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
16 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
162 |
95 |
$1K |
| D2140 |
|
19 |
13 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
14 |
12 |
$919.91 |