| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,390 |
1,387 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,654 |
1,653 |
$37K |
| D0274 |
Bitewings - four radiographic images |
887 |
885 |
$22K |
| D1206 |
Topical application of fluoride varnish |
979 |
978 |
$18K |
| D1120 |
Prophylaxis - child |
577 |
577 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
320 |
317 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
61 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
426 |
166 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
344 |
335 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
31 |
24 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
109 |
106 |
$2K |
| D0272 |
Bitewings - two radiographic images |
39 |
39 |
$962.93 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$744.45 |
| D1999 |
|
30 |
26 |
$0.00 |