| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
208 |
204 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
126 |
123 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
80 |
80 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
27 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
12 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
103 |
102 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
25 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$0.00 |