| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
258 |
258 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
370 |
370 |
$10K |
| D0274 |
Bitewings - four radiographic images |
225 |
225 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
62 |
52 |
$5K |
| D1120 |
Prophylaxis - child |
103 |
103 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
293 |
291 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
172 |
172 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
291 |
291 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
179 |
179 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$430.00 |
| D0270 |
|
27 |
27 |
$355.16 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$346.25 |