| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
735 |
732 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
347 |
344 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
383 |
383 |
$4K |
| D0274 |
Bitewings - four radiographic images |
441 |
438 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
18 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
336 |
329 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
477 |
460 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
84 |
82 |
$931.30 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$405.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
38 |
38 |
$381.50 |
| D1999 |
|
16 |
15 |
$0.00 |