| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,734 |
1,726 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
2,393 |
2,373 |
$47K |
| D1206 |
Topical application of fluoride varnish |
2,212 |
2,185 |
$37K |
| D1120 |
Prophylaxis - child |
660 |
646 |
$20K |
| D0274 |
Bitewings - four radiographic images |
653 |
651 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
200 |
194 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
39 |
26 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$816.41 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$285.33 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$163.70 |