| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,053 |
1,051 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
936 |
934 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
345 |
345 |
$8K |
| D0274 |
Bitewings - four radiographic images |
526 |
525 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
126 |
122 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
61 |
28 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
57 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
130 |
130 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
272 |
269 |
$1K |
| D1120 |
Prophylaxis - child |
36 |
36 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$100.80 |
| D1999 |
|
346 |
337 |
$0.00 |