| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
138 |
137 |
$200.00 |
| D0120 |
Periodic oral evaluation - established patient |
24 |
24 |
$84.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
73 |
$76.00 |
| D1206 |
Topical application of fluoride varnish |
144 |
143 |
$19.00 |
| D0220 |
Intraoral - periapical first radiographic image |
107 |
106 |
$0.00 |
| D1110 |
Prophylaxis - adult |
78 |
78 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
24 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
107 |
107 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$0.00 |
| D1330 |
|
218 |
218 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$0.00 |