| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
103 |
103 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
59 |
59 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
60 |
59 |
$1K |
| D1206 |
Topical application of fluoride varnish |
50 |
50 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
30 |
30 |
$725.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
30 |
$725.00 |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$300.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
31 |
31 |
$210.00 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
39 |
$165.00 |