| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
455 |
454 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
518 |
517 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
815 |
812 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
143 |
143 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
158 |
157 |
$8K |
| D1120 |
Prophylaxis - child |
92 |
92 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
24 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
26 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
203 |
122 |
$2K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$248.40 |
| D1999 |
|
12 |
12 |
$0.00 |