| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
84 |
83 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
94 |
73 |
$2K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$996.00 |
| D0120 |
Periodic oral evaluation - established patient |
52 |
45 |
$704.00 |
| D0140 |
Limited oral evaluation - problem focused |
37 |
30 |
$140.00 |
| D0220 |
Intraoral - periapical first radiographic image |
97 |
67 |
$26.00 |
| D0270 |
|
16 |
12 |
$22.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
13 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$0.00 |
| D1330 |
|
148 |
112 |
$0.00 |
| D1310 |
|
88 |
65 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
13 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
69 |
35 |
$0.00 |
| D0603 |
|
15 |
12 |
$0.00 |