| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,274 |
1,273 |
$25K |
| D1110 |
Prophylaxis - adult |
450 |
450 |
$16K |
| D0330 |
Panoramic radiographic image |
531 |
531 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
252 |
117 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
52 |
25 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
333 |
317 |
$3K |
| D9110 |
|
180 |
180 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
27 |
$2K |
| D2140 |
|
27 |
12 |
$958.68 |
| D0272 |
Bitewings - two radiographic images |
69 |
69 |
$751.86 |
| D1208 |
Topical application of fluoride, excluding varnish |
38 |
38 |
$417.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
71 |
71 |
$379.59 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$125.42 |