| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
360 |
360 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
510 |
510 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
130 |
93 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
49 |
$5K |
| D1120 |
Prophylaxis - child |
78 |
78 |
$3K |
| D0274 |
Bitewings - four radiographic images |
281 |
281 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
461 |
461 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
179 |
179 |
$2K |
| D2140 |
|
47 |
44 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
356 |
356 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
109 |
109 |
$2K |
| D2331 |
|
20 |
12 |
$2K |
| D2160 |
|
15 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
20 |
$1K |
| D1206 |
Topical application of fluoride varnish |
17 |
17 |
$510.00 |
| D0270 |
|
34 |
34 |
$447.96 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$244.00 |