| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,940 |
1,936 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
2,800 |
2,796 |
$61K |
| D1120 |
Prophylaxis - child |
1,259 |
1,256 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,535 |
1,531 |
$33K |
| D0274 |
Bitewings - four radiographic images |
643 |
642 |
$17K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
40 |
28 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
16 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
67 |
$921.45 |
| D0272 |
Bitewings - two radiographic images |
41 |
41 |
$798.18 |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$741.09 |
| D2140 |
|
14 |
13 |
$509.08 |
| D1999 |
|
36 |
36 |
$0.00 |