| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
349 |
349 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
548 |
548 |
$13K |
| D0274 |
Bitewings - four radiographic images |
254 |
254 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
525 |
519 |
$5K |
| D1120 |
Prophylaxis - child |
109 |
109 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
243 |
243 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
371 |
371 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
220 |
220 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
21 |
16 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
27 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
16 |
$1K |
| D0270 |
|
92 |
90 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
60 |
60 |
$860.00 |
| D1206 |
Topical application of fluoride varnish |
28 |
28 |
$840.00 |