| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
520 |
519 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
354 |
354 |
$9K |
| D1206 |
Topical application of fluoride varnish |
337 |
336 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
69 |
69 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
89 |
89 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
14 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
114 |
114 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
83 |
54 |
$730.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$582.00 |
| D1999 |
|
16 |
16 |
$0.00 |