| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
238 |
237 |
$12K |
| D0274 |
Bitewings - four radiographic images |
228 |
228 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
173 |
173 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
234 |
234 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
75 |
75 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
24 |
$4K |
| D1120 |
Prophylaxis - child |
88 |
88 |
$3K |
| D1206 |
Topical application of fluoride varnish |
136 |
136 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
29 |
16 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$1K |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$712.10 |
| D0220 |
Intraoral - periapical first radiographic image |
35 |
33 |
$499.38 |