| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
211 |
211 |
$4K |
| D1110 |
Prophylaxis - adult |
99 |
99 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
246 |
246 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
146 |
141 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
196 |
195 |
$2K |
| D0274 |
Bitewings - four radiographic images |
103 |
103 |
$2K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$938.56 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
29 |
$581.04 |
| D0220 |
Intraoral - periapical first radiographic image |
203 |
196 |
$352.11 |
| D4341 |
|
104 |
31 |
$0.00 |
| D4910 |
|
31 |
31 |
$0.00 |
| D2950 |
|
38 |
12 |
$0.00 |
| D0330 |
Panoramic radiographic image |
75 |
75 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
13 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
70 |
27 |
$0.00 |
| D2394 |
|
32 |
13 |
$0.00 |
| D3120 |
|
85 |
21 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
45 |
18 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
15 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
16 |
$0.00 |