| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
134 |
133 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
230 |
228 |
$6K |
| D1120 |
Prophylaxis - child |
128 |
128 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
67 |
46 |
$4K |
| D0274 |
Bitewings - four radiographic images |
154 |
154 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
188 |
188 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
76 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
220 |
214 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
14 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
40 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
174 |
152 |
$1K |
| D2160 |
|
15 |
12 |
$1K |