| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
217 |
214 |
$5K |
| D0274 |
Bitewings - four radiographic images |
269 |
266 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
312 |
309 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
569 |
551 |
$4K |
| D1120 |
Prophylaxis - child |
205 |
204 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
198 |
196 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
293 |
291 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
777 |
466 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
84 |
50 |
$3K |
| D0272 |
Bitewings - two radiographic images |
91 |
91 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
73 |
68 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$863.80 |
| D1999 |
|
396 |
349 |
$0.00 |