| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
725 |
725 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,087 |
1,087 |
$32K |
| D1120 |
Prophylaxis - child |
713 |
713 |
$30K |
| D0274 |
Bitewings - four radiographic images |
283 |
283 |
$11K |
| D1206 |
Topical application of fluoride varnish |
221 |
220 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
391 |
388 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
236 |
236 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
138 |
138 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
280 |
280 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
52 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
14 |
$1K |
| D1999 |
|
194 |
171 |
$0.00 |