| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,228 |
1,223 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
2,143 |
2,133 |
$8K |
| D0274 |
Bitewings - four radiographic images |
1,719 |
1,712 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,952 |
1,943 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
2,039 |
2,025 |
$3K |
| D1120 |
Prophylaxis - child |
746 |
744 |
$86.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
71 |
50 |
$0.00 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
36 |
30 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
726 |
724 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
13 |
$0.00 |