| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
278 |
278 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
286 |
286 |
$7K |
| D1206 |
Topical application of fluoride varnish |
296 |
296 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
13 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
71 |
71 |
$3K |
| D1110 |
Prophylaxis - adult |
53 |
53 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
140 |
135 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
112 |
65 |
$801.75 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$746.28 |
| D1999 |
|
33 |
33 |
$0.00 |