| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
537 |
537 |
$17K |
| D1110 |
Prophylaxis - adult |
740 |
740 |
$16K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
245 |
100 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
467 |
467 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
373 |
373 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
162 |
75 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
40 |
26 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
260 |
259 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
22 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
328 |
324 |
$1K |
| D0190 |
|
233 |
233 |
$1K |
| D0274 |
Bitewings - four radiographic images |
82 |
82 |
$1K |
| D2160 |
|
17 |
12 |
$803.25 |
| D1120 |
Prophylaxis - child |
24 |
24 |
$630.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$273.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$189.00 |