| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
436 |
425 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
373 |
361 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
167 |
73 |
$16K |
| D9211 |
|
574 |
362 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
79 |
29 |
$6K |
| D0274 |
Bitewings - four radiographic images |
177 |
169 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
102 |
102 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
209 |
200 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
334 |
302 |
$3K |
| D0330 |
Panoramic radiographic image |
34 |
34 |
$2K |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$713.18 |
| D0460 |
|
13 |
13 |
$0.00 |