| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
141 |
125 |
$5K |
| D1110 |
Prophylaxis - adult |
120 |
107 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
161 |
154 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
121 |
$3K |
| D1206 |
Topical application of fluoride varnish |
226 |
202 |
$3K |
| D0274 |
Bitewings - four radiographic images |
120 |
104 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
26 |
13 |
$970.50 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
13 |
$895.32 |
| D0272 |
Bitewings - two radiographic images |
64 |
52 |
$824.04 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$768.92 |
| D0220 |
Intraoral - periapical first radiographic image |
76 |
68 |
$487.44 |
| D0431 |
|
154 |
139 |
$170.00 |